Dermalogica Facial – Comprehensive Consent and Concern Form

Client Information

Full Name *

Date of birth *

Gender *

Address

Street Address

City

Postal code

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Medical History

Are you currently under medical supervision or taking medications? *

Yes

No

If yes, please provide details: *

If you had any allergie or other medical condition please specify :

Do you have any metal implants or pacemaker? *

Yes

No

Are you currently using any topical/oral medications (e.g., Retin-A, Accutane)? *

Yes

No

If yes, list medications and duration:

Treatment Goals and History

What is your primary concern regarding your skin *

Have you had any cosmetic procedures within the last 3 months (laser, fillers, peels)? *

Yes

No

If yes, please lest us know :

Do you use SPF daily? *

Yes

No

Treatment Expectations & Preferences

Have you had a professional facial before *

Yes

No

If yes, when was your last treatment?

What are your goals with today’s Dermalogica facial?

Are there any specific products or ingredients you wish to avoid? *

Yes

No

If yes, please list:

Risks, Side Effects, and Acknowledgements

Please you should read and initial each statement regarding Dermalogica Facial : *

I understand that a Dermalogica facial is a non-invasive skincare treatment designed to improve the health and appearance of the skin.c

I acknowledge that temporary redness, sensitivity, or breakouts may occur post-treatment.

I agree to disclose all skin sensitivities and allergies prior to treatment.

I understand that individual results vary and this treatment is not a cure for skin conditions.

I will follow all home care instructions and recommendations provided by the practitioner.

I understand that it is my responsibility to inform the practitioner of any discomfort during the session.

I consent to photos being taken for documentation purposes. These will not be shared without written permission.

Client Declaration and Consent

Check all boxes for the Dermalogica Facial : *

I confirm that the information provided is accurate and complete to the best of my knowledge.

I understand the nature of the Dermalogica facial, potential risks, and expected outcomes.

All my questions have been answered and I consent to receiving this treatment at Idens Laser Clinic.

By signing below, I confirm that I have read and understood the information provided and consent to proceed with the treatment.

Client Signature: *

Clear

Date: *

Practitioner Name (Print): *

Practitioner Signature: *

Clear

Date: *

I agree to terms & conditions provided by the company.

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Dermalogica Facial – Comprehensive Consent and Concern Form

Treatment Goals and History

Treatment Expectations & Preferences

Risks, Side Effects, and Acknowledgements

Client Declaration and Consent

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