Skin Peel "*" indicates required fields CLIENT DETAILSFull Name Email* Date MM slash DD slash YYYY Address Mobile* Suburb Postcode Desired Outcome LIFESTYLEOccupation Exercise 0 times a week 1 - 3 times a week 4 - 7 times a week Water Intake 0 - 3 glasses a day 1 - 2 litres a day 2 - 3 litres a day Stress Levels Low Moderate High Sleep 0 - 5 hours a night 6 - 7 hours a night 8+ hours a night Diet Poor Moderate Balanced Digestion Sluggish Regular Imbalanced Smoking Yes No SKINCARE PRODUCTS Please tick if you have used products containing any of the following ingredients on the area to be treated:Skincare Products Benzoyl Peroxide Or Adapalene (Differin) Alpha Beta Hydroxy Acids (Glycolic Acid, Salicylic Acid) Hydroquinone, Azelaic Acid, Kojic Acid Retinoids (Vitamin A) Do You Wear SPF Daily? Yes No How Long Since You Last Exfoliated The Treated Area? Current Skincare Routine/Brands?Current Skincare Routine/Brands? Hair Removal (Wax, Threading Etc) Injectables/Botox Microdermabrasion Cosmetic Tattoo, Tattoos Skin Needling Plastic Surgery Radio Frequency (RF) Laser or IPL Other Please tick if you have had any of the following procedures:Other Skin Care Sun Exposure Yes No MEDICATION Medical History Pregnant Breastfeeding Psoriasis / Eczema Herpes / Cold Sores Cancer Warts or Skin Tags Diabetes Scleroderma Shingles Rosacea Facial Vitiligo Roaccutane Congenital / Idiopathic Methemoglobinemia Liver Disease (Ie Hepatitis) Skin Cancer / Unusual Moles Moles That Have Changed, Itched or Bled Antibiotics in the Last Months HIV (Human Immunodeficiency Virus) Medication That Causes Photosensitivity Blood Thinners (E.G. St Johns Wart, Anti-Coagulants Etc) Actinic Keratosis (Solar) Photosensitive Disorder (i.e. Lupus) Low Immune System (Current or in the last month) Acne Sensitive/ Irritated Skin Other Allergies Other Medical History Other Allergies MedicationI acknowledge this is an elective skin treatment. I have been provided with adequate information and the opportunity to ask questions and seek clarification regarding this treatment procedure and its alternatives including no treatment at all. The treatment procedure, its benefits and potential risks have been adequately explained and understood by me to my satisfaction. I have been given an individual treatment plan with pre and post care instructions and agree to follow these with the support of my therapist to the best of my ability or otherwise contact my therapist or doctor if I am unsure. Every precaution will be taken to prevent complications and although rare, they can sometimes occur. I am aware of and accept the risk of rare and unforeseen complications which may not have been discussed and may result from this treatment. I will notify my therapist immediately if any unexpected events occur. I have disclosed my full and complete medical history and discussed my realistic cosmetic expectations to the best of my abilities. I will notify my therapist of any changes in my health status during my series of treatments that can increase potential risks or reduce efficacy.MEDICATION AGREEMENT The treatment has been explained to me and all my questions answered to my satisfaction I am aware of the benefits of using the pre and post skin care products as directed by my therapist I am aware that a complete series of at least 4 treatments is recommended to achieve the best results. I understand there may be between 1 hour up to 48 hours of “downtime” (redness, puffiness, sensitivity) after each peel treatment I consent to my photo being taken and stored electronically. I consent to my photograph being taken for use of before and after examples in marketing for Earth and Skin Pty Ltd. I have answered the client consent form truthfully and have disclosed all medical history and medications to the best of my knowledge. I am aware that a $50 Consultation with my skin therapist is required prior to starting Skin Needling and that this fee is redeemable in product from our Spa Retail. This fee is applicable even in the unlikely event that I am not a candidate for Skin Needling Full Name SignatureDate MM slash DD slash YYYY ORGANIC SKIN PEEL CONSENT FORM PHYT’SKIN RENOV Organic Skin Peel is the first certified organic chemical peel with 30% Glycolic Acid of natural origin from filtered sugar cane extract. It is an excellent fruit acid with a small molecular size, which ensures skin penetration and stimulation of cell activity within the deeper layers of the skin. The peel eliminates dead skin cells and regenerates new skin cells. Transforming damaged and ageing skin to a healthy radiant glow with no downtime. A chemical peel can target concerns of acne scarring, uneven skin tone, texture, pore size and wrinkles/fine lines. Results are noticeable after one treatment, however to achieve optimal results we recommend a series of four treatments, every 10-14 days. PHYT’SKIN RENOV has proven to be effective for 90% smoother skin, 95% refined texture & 80% reduced imperfections*. Keeping in mind individual results vary and depend on many factors; thus it is extremely difficult to advise on the exact number of treatments required to achieve each individual’s desired outcome. *clinical study on 20 women from age 40-60. What to Expect You are kept comfortable and relaxed throughout, most clients experience a mild itchy tingling sensation for the ten minutes the peel is on. Minor redness and very mild heat are normal and usually come down within 1 hour of the treatment. Very rarely the skin may stay red for up to 24 hours. We advise having your peel treatment late afternoon/night and plan to be indoors with no makeup for at least 24 hours post your treatment. From there, there may be less downtime in your following sessions, once we see how the skin responds. Skin may feel rough, tight, dry or flaky for 2-7 days following treatment as the skin rejuvenates - you may then gently exfoliate after 7 days. You will be given a tailored pre/post treatment plan directed by your therapist. (Please see the attached pre and post care information sheet for further instructions also). Possible side effects Even though the risks associated are extremely low, the following can occur: • Possible side effects can include: temporary discomfort, flushing, purging/detox breakout, histamine reaction, bruising, blistering, swelling, stinging, itching, tender, rough, dry or flaking skin. • In very rare instances risks associated may include: crusting, scarring, freckles may temporarily lighten or disappear, hyperpigmentation/hypopigmentation and/or infection can occur. • A history of cold sores may result in an outbreak therefore prophylactic treatment is strongly recommended prior to and following treatment. • Potential risk of chemical burn if instuctions/advice for pre/post care from your therapist is not followed. If extreme heat, burning sensation and/or blistering occurs do not touch, pick or apply anything to the skin other than a clean cold gentle compress. Monitor symptoms and immediately contact your therapist and/or medical professional. • Other potential risks include allergic reaction and/or failure to achieve desired result. General caution If you have a medical condition, please seek independent advice and obtain written consent from your treating Doctor. Risk of developing an unknown allergic reaction to allergen. In the event of rash or anaphylaxis the treatment will cease and immediate medical attention will be sought. Risk of infection due to intentional micro injury to the skin surface. Maintaining meticulous hygiene practices pre and post treatment is advised. Risk of developing Delayed Hypersensitivity Allergic Reaction. Presenting as onset of chronic erythema days to weeks following treatment progressing to systemic infection. Signs and symptoms include: joint pain, low grade fever, fatigue and red nodules under the skin. Monitor and advise your therapist if you have any concerns. Risk of developing Post Inflammatory Hyperpigmentation. Presenting as darkened patches on skin due to increased inflammation in skin. TREATMENT SERIES I certify that all the information given on the previous client form is still correct and true. I have not had any of the following: • Sun exposure in the last 4 weeks • Change in medication • Been under doctor’s care or supervision • Any surgery / injectable • Pregnancy/ trying to get pregnant or breastfeeding I will advise ............................................................. of any changes that occur during my treatment that can increase potential risks or reduce efficacy I also understand that there will be no refund for any performed services.Full Name Date MM slash DD slash YYYY SignatureWitness: Treatment 1SignatureClinician Witness Date MM slash DD slash YYYY Treatment 2SignatureClinician Witness Date MM slash DD slash YYYY Treatment 3SignatureClinician Witness Date MM slash DD slash YYYY Treatment 4SignatureClinician Witness Date MM slash DD slash YYYY Treatment 5SignatureClinician Witness Date MM slash DD slash YYYY Treatment 6SignatureClinician Witness Date MM slash DD slash YYYY Treatment 7SignatureClinician Witness Date MM slash DD slash YYYY Treatment 8SignatureClinician Witness Date MM slash DD slash YYYY Treatment 9SignatureClinician Witness Date MM slash DD slash YYYY Treatment 10SignatureClinician Witness Date MM slash DD slash YYYY Treatment 11SignatureClinician Witness Date MM slash DD slash YYYY Treatment 12SignatureClinician Witness Date MM slash DD slash YYYY
