Skin and Medical Health Questionnaire Please complete the following skin and health questionnaire to allow us better serve you and your skincare needs. Today's Date * MM DD YYYY Title * Miss Mrs Ms Mr First Name * Last Name * DOB * MM DD YYYY Preferred contact number * (###) ### #### Email address * Physical address * City * State/Province * Zip/Postal Code * Emergency contact name * Emergency contact phone number * (###) ### #### Who should we thank for referring you? * Ethnicity * White Black African American Middle eastern Asian Hispanic or Latino Multiracial What is your skin tone? Select one that best describes your skin color: * Light, Pale white, very fair. Always burns, never tans. White, fair. Usually burns, sometimes tans. Cream white. Sometimes burns, always tans. Olive, moderate brown. Rarely burns, tans with ease. Brown, dark brown. Very rarely burns, tans easily. Black, very dark brown to black. Never burns, always tans. None of the above Have you been under the care of a plastic surgeon, dermatologist or an esthetican within the past year? * Yes No If yes, what for? Have you received any treatments on your face in the last 90 days? * Chemical peels HydraFacial Skin tightening Microneedling Laser hair removal Microdermabrasion Facial Facial waxing Laser rejuvenation Dermaplaning None of the above Any recent surgery, including plastic surgery? * Yes No If yes, please explain: Have you been diagnosed with skin cancer? * Yes No If yes, please indicate when and where on your body? Have you ever been diagnosed with any of the following conditions? * Please check all that apply Cancer Asthma Hormonal imbalance Rosacea Immune disorder Eczema Herpes simplex/cold sore (some procedures may cause reactivation) Diabetes (uncontrolled) High blood pressure Keloid scarring Migraine HIV/AIDS Clotting abnormalities Thyroid condition Lupus Pacemaker/metal pins in body Seizures Hepatitis PCOS Chronic skin disorder Hemophilia Psoriasis Anemia Hysterectomy None of the above Do you currently or in the past, have used any of the following medications/ingredients? * Salicylic acid Glycolic acid Lactic acid Hydroquinone Clindamycin Tetracycline Retin A/Retinol Benzoyl peroxide Renova Tazorac Marijuana Cocaine/Speed Accutane Doxycycline Minocycline Erthromycin Differin Aczone None of the above What condition(s) were you treating with these ingredients/medications and when was the last time you used them? Do you have trouble healing? * Yes No Do you smoke? * Yes No How often do you exercise? * Indicate your daily consumption of water * Indicate your daily consumption of caffeinated beverages * Indicate your daily consumption of alcoholic beverages * How often do you consume the following foods: Fast food * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Whey/soy protein * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Peanuts/Peanut butter * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Sushi * Daily Weekly Monthly 2-3 timer per year Never How often do you consume the following foods: Miso soup * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Microwave popcorn * Daily Weekly Monthly 2-3 timer per year Never How often do you consume the following foods: Sugary snacks * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Salty snacks * Daily Weekly Monthly 2-3 timer per year Never How often do you consume the following foods: Milk/yogurt * Daily Weekly Monthly 2-3 times per year Never How often do you consume the following foods: Cheese * Daily Weekly Monthly 2-3 timer per year Never How often do you consume the following foods: Shellfish (shrimp, crab, lobster, clam, oyster and mussels) * Daily Weekly Monthly 2-3 timer per year Never How often do you consume the following foods: Kelp and seaweed * Daily Weekly Monthly 2-3 times per year Never What is your stress level on a daily basis? * Common stressors = Job loss; new job; wedding; romantic breakup; death in the family or close friend; graduation; difficult home life; long commute; heavily scheduled. High Medium Low Do you work over night? * Yes No Do you work around chemicals, tars, oils, grease, or ink? * Yes No Do you use fabric softener in the dryer? * Yes No Are you pregnant? * Yes No Are you nursing? * Yes No Do you use birth control pills, shots, or use IUD? * Yes No If yes, which do you use? Have you ever experienced claustrophobia? * Yes No Do you form thick or raised scars from cuts or burns? * Yes No Have you ever had a reaction to a skincare product? * Yes No If yes, to what products? And what did you experience? Rash Irritation Peeling Swelling Sun sensitivity Breakout None of the above/Other Have you been exposed to the sun (at the beach, lake, or pool), used a tanning bed, or tanning lotions in the past 72 hours? * Yes No If yes, which one? Do you have known allergies? * Yes No If yes, please list: Are you allergic to any anesthetics (any of the caines)? * Yes No If yes, which one Are you allergic to any metals? * Yes No Are you allergic to any of the following? * Aspirin Latex Sulfur None of the above List all the medications you take regularly including vitamins, and over the counter medications: * What skincare product(s) are you currently using? * Cleanser Serums Exfoliants (acid, scrubs) Acne medication Masks Sunscreen Toner Moisturizer Tinted moisturizer/spf Micellar water Balms Foundation Other None of the above What is the reason for your visit today and what do you wish to change about your skin? * Do you receive botox? * Yes No Are you interested in cosmetic injectables? * Yes No I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform my esthetician, Maedeh Samimi of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Maedeh Samimi and Urban Skin Care Clinic from liability and assume full responsibility thereof. Name * Today's Date * MM DD YYYY CANCELLATION POLICY Arrival Time: We understand that delays can happen and we will do our best to accommodate you, however, we need to keep other clients and Urban Skin Care Clinic on time, therefore, if a client arrives 15 minutes past their scheduled time, we may have to reschedule their appointment. Sickness Or Family Emergency: We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family, however, when you do not call, text or email us to cancel or reschedule your appointment, you may be preventing another client from getting much needed treatment. Conversely, the situation may arise where another client fails to cancel their appointment within timely manner and we are unable to schedule you for a visit. Rescheduling or Canceling an appointment: We kindly request 48 hour advance notice for all cancellations and rescheduling. We reserve the right to charge $50 to your card on file, if you do not show up to your appointment. * Name Today's Date * MM DD YYYY PHOTOGRAPH & VIDEO RELEASE FORM I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or videotape. without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse commercial settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes: ● commercial presentations ● online music video platforms (YouTube, Vimeo, etc) ● television or broadcast media distribution ● Social media posts ● Digital advertisement ● Website. By signing this release I understand this permissible sion signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public business settings. I will be consulted about the use of the photographs or video recording for any purpose other than those listed above. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for entertainment purposes. Yes No Name First Name Last Name Today's Date * MM DD YYYY INFORMED CONSENT FORM I hereby consent to and authorize Maedeh Samimi with Urban Skin Care Clinic to perform any of the following treatment(s)/procedure(s): Chemical Peels; Dermaplaning; Microdermabrasion; Facials; Microneedling; Microcurrrent; Ultrasonic Skin Scrubber; Microchanneling by Procell Therapies, and Nd:YAG Neo Elite laser by Aerolase on my face and or body. Chemical Peels; Dermaplaning; Microdermabrasion; Facials; Microneedling; Microcurrrent; Ultrasonic Skin Scrubber; Microchanneling by Procell Therapies, and Nd:YAG Neo Elite laser by Aerolase are elective procedures for cosmetic purposes only, and I voluntarily agree to undergo these treatment(s)/procedure(s) after the nature and purpose of these treatment(s)/procedure(s) have been explained to me, along with the risks and hazards involved. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. Nd:YAG LASER: The LightPod Neo® (Nd:YAG 1064nm) laser is FDA approved for a variety of procedures including hair removal, vein treatment and wrinkle reduction. This form is designed to give you the information you need to make an informed choice of whether or not to undergo Nd:YAG laser treatment. If you have any questions, please do not hesitate to ask. Although the laser treatment is effective in most cases, no guarantee can be made that a specific patient will benefit from the treatment. The laser emits an intense beam of light that is absorbed in specific body tissues within the skin, and depending upon the type of procedure, several treatments may be required at intervals specified by the provider. Some of the possible complications of Nd:YAG laser treatment are: Discomfort – The procedure(s) are done so precisely that surrounding tissue is minimally affected; the patient may experience a mild sensation of pain in the treated areas. Some degree of skin flushing may occur, but it typically resolves within several hours. * Initials Scarring – There is a small chance of scarring, including hypertrophic scars, or very rarely, keloid scars. Keloid scars are very heavy raised scar formations. To minimize chances of scarring, it is important that you follow all postoperative instructions carefully. It is important that any prior history of unfavorable healing be reported. * Initials Pigmented changes – The treated area may heal with lighter or darker pigmentation. This occurs more often in darker pigmented skin and following exposure of the area to the sun. It is recommended that you protect yourself from any sun exposure for at least three months following treatment. Hyperpigmentation usually fades in three to six months. However, pigment change can be permanent. * Initials Lack of Treatment Response – There is a possibility that the targeted hairs, veins or other treated areas will not respond to the treatment. This is often a function of the specific body chemistry of the patient, including relative pigmentation and light absorption characteristics of the patient’s various body tissues. * Initials Eye Exposure – There is also the risk of harmful eye exposure to laser beam. Safeguards will be provided by the laser practitioner. It is important that you keep your eyes closed and have protective eye wear at all times during the laser treatment. * Initials I understand that it is imperative to my health and safety that I disclose ALL of the information requested in the Skin and Medical Health Questionnaire. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications. * Initials I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost. * Initials I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult with Maedeh Samimi immediately. * Initials I understand that if I choose to consult a physician, I do so at my own expense. * Initials I consent to “before-and-after” photographs for the purpose of documentation. * Initials I understand that if I have any concerns, I will address these with Maedeh Samimi and I give permission to her to perform all treatments/procedures we have discussed. * Initials I understand my technician/esthetician (Maedeh Samimi) will take every precaution to minimize or eliminate negative reactions as much as possible. * Initials I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. * Initials I understand the procedure(s) and accept the risks. * Initials I am not under the influence of alcohol, drugs, or any other substances. * Initials I do not hold Maedeh Samimi or Urban Skin Care Clinic responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment(s) performed today and in the future at Urban Skin Care Clinic. * Initials I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. * Initials I furthermore indemnify Maedeh Samimi herein, and hold harmless and nameless from any and all liability, claims, demands, judgments, costs, and expenses arising out of any claims relating to the procedure authorized herein. * Initials Today's Date * MM DD YYYY Thank you
