Name
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First Name
Last Name
Date of Birth
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YYYY
Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
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(Medication refers to prescription drugs, herbal supplements, vitamins, etc.)
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(Food, environmental, etc.)
Check any that you experience once or more per week:
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Have you ever had/used:
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How would you describe your skin? Please mark all that apply.
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Have you had any of the following past or present?
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1-3 no stress / 4-7 manageable / 8-10 unmanageable
I have been feeling…
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(Caffeine refers to coffee, tea, soft drinks, or any other caffeinated beverages.)
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What do you consume on a daily basis?
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I agree to the following:
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I have completed the client’s medical form accurately. I have been candid in revealing any condition that could prohibit my treatment or future treatment such as cold sores, pregnancy, use of hormones, recent facial surgery or laser resurfacing, recent use of Retin-A, or use of Accutane within the last twelve months.
I understand that there are no guaranteed results from my treatments. Many variables such as age, sun damage, ongoing sun exposure, smoking, excessive alcohol intake, climate, diet and water intake, skin thickness, and sensitivity can interfere with my results.
I understand that I may or may not peel with a clinical chemical peel and that each case is individual. Regardless of the precautions taken, I acknowledge the possibility of an adverse reaction to any facial treatment or clinical procedure.
I accept sole responsibility for any medical care that may become necessary and will immediately contact the Esthetician performing the treatment of any adverse reactions.
In the case of clinical procedures that cause an intentional wound-healing cascade, I will not scratch, pick, pull at, or abrade the treated skin that is healing.
I understand that to achieve maximum results the recommended home care routine must be followed. I understand that if I alter the routine or use products not recommended by the skin care professional the results could be altered or inhibitive. I also understand that it may take several treatments to obtain the desired results.
I understand that the following side effects or complications can occur:
I understand the goals of the treatment as well as the limitations and possible complications. The professional esthetician provided the information and answered all my questions concerning this procedure or future procedures.
I clearly understand the above information.
Informed Consent
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I UNDERSTAND THAT TREATMENTS PROVIDED AT CLAUDIA COLOMBO SKIN WELLNESS ARE FOR THE PURPOSE OF STRESS REDUCTION, RELIEF FROM MUSCULAR TENSION OR SPASM, INCREASING CIRCULATION AND CLEANSING THE SKIN. AND PERFORMING CLINICAL AESTHETICS TREATMENTS FOR ENHANCING THE FACE AND BODY.
I UNDERSTAND THAT YOUR THERAPISTS DO NOT DIAGNOSE ILLNESS, DISEASE, OR ANY OTHER PHYSICAL OR MENTAL DISORDER. AS SUCH YOUR THERAPIST DOES NOT PRESCRIBE MEDICAL TREATMENT OR PHARMACEUTICALS, NOR DO THEY PERFORM ANY SPINAL MANIIPULATIONS. IT IS CLEAR TO ME THAT SPA THERAPIES ARE NOT A SUBSTITUTE FOR MEDICAL EXAMINATIONS AND/OR DIAGNOSES, AND THAT IT IS RECOMMENDED THAT I SEE A PHYSICIAN FOR ANY PHYSICAL AILMENT THAT I MIGHT HAVE BECAUSE A THERAPIST MUST BE AWARE OF EXISTING PHYSICAL CONDITIONS. I HAVE STATED ALL MY KNOWN MEDICAL CONDITIONS AND TAKE IT UPON MYSELF TO KEEP THE THERAPIST UPDATED ON MY PHYSICAL HEALTH. I DO NOT HOLD THE THERAPIST RESPONSIBLE FOR ANYTHING THAT MIGHT OCCUR FROM ANY UNKNOWN AILMENT OR MISINFORMATION.
I UNDERSTAND AROMATHERAPY IS A HEALING ART AND SCIENCE THAT SUPPORTS AND ENHANCES THE INDIVIDUAL ABILITY TO HEAL AND MAINTAIN HEALTH. I UNDERSTAND THAT THIS FORM IS DESIGNED TO GATHER INFORMATION SO THAT MY PRACTITIONER CAN DESIGN AND CREATE SPECIFIC TREATMENTS AND RECOMMEND PRODUCTS BASED ON MY UNIQUE NEEDS AND GOALS.
Since essential oils and other ingredients should not be used under certain circumstances, I affirm that I have truthfully answered all questions about my health on the Medical/Aromatherapy Intake Form.
I hold my Aesthetician and Clinical Aromatherapist, Claudia Colombo harmless for any injuries or negative effects I may experience as a result of receiving treatment or using the products I receive from this treatment and consultation.
Claudia Colombo Skin Wellness upholds strict confidentiality.
