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620 Jones Street @ Geary | San Francisco | 415-496-6858
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New to MedEsthetics Rx? Then come right this way...
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New Client Form
Name
Phone Number (for confirming apt.)
Date Of Birth
How did you hear about us?
*
Check any of the following procedures you have had:
Cosmetic Surgery
Botox or Dysport Injections
Laser Resurfacing/IPL
Dermaplaning
Chemical Peels
Microneedling/CRT
Other
Are you currently using any of the following?
Retinoids: Retinol, RetinA, Renova
AHA/BHA (Glycolic, Salicylic acids)
Accutane (within one year)
Topical Vitamin C
Hydroquinone
Have you ever had an allergic reaction to any skin products (cosmetic or internal)?
Yes
No
If yes, please specify
Are you allergic to aspirin?
Yes
No
What products are you currently using?
Place a check next to conditions in which you want to improve or change:
Hyperpigmentation (brown spots)
Acne
Acne Scarring
Sun Damage
Enlarged Pores
Fine lines/wrinkles
Rosacea/Redness
Surgical Facial Scarring
Other
Have you had skin treatments before (facials)?
Yes
No
Have you had any adverse reactions to any skincare treatments in the past?
Yes
No
Do you use sunscreen or sunblock? (If yes, please specify brand)
Have you had laser treatments, electrolysis, waxing in the past week?
Yes
No
What are your expectations for today's treatment and long term goal?
Patient Waiver
Please initial all of the following.
Please check all of the following
*
I understand this is Not a Spa Facial treatment. I understand that the in-practice procedure is a cosmetic skin rejuvenation treatment and that I may need several administrations of the procedure in order to achieve my best results. (once ever 4-8 weeks)
I understand that an at home skincare regimen designed by your technician will help enhance and maintain the in-office treatments.
I understand that all home care products recommended by your technician can only be recommended from buying directly from MedEstheticsRX. China has been bootlegging many skincare products and machines. Consumers are having adverse reactions to some products. PLEASE BE AWEARE THAT WE CAN ONLY GUARANTEE THE PRODUCT EFFICACY IF BOUGHT DIRECTY FROM US (MEDESTHETICSRX).
I understand that it is important to strictly follow at home care instructions for optimal results. I will notify MedEstheticsRX if I experience any adverse reactions or side effects that appear to be attributable to my use of home care products and discontinue use of the products until otherwise advised.
Most do not experience side effects, however, I understand there may be some degree of discomfort, such as stinging, pinpricking sensations, heat and or tightness of the skin. I may also experience mild redness, peeling, mild scabbing or increase/decrease in pigmentation, which is usually temporary. Infection is extremely unlikely but may occur.(Ask you physician for anti-viral medication if you are prone to herpes/cold sores.)
If the Dermaplaning phase is administered; hair is expected to come back with mild bluntness to the hair end. New Hair WILL NOT appear darker or denser.
I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, condition of my skin, sun damage, smoking, climate, etc… I understand that I may or may not peel and that each case is individual.
Before and after photos will be taken to keep progress of the client skin improvements. I authorize MedEstheticsRX to use the photos for advertising and/or media. No identification will be attached in any advertising material.
I understand I will be more sun sensitive and I agree to reframe from tanning either in a booth or outdoors while I am undergoing skin treatments or at home skincare from MedEstheticsRx. At home skincare and in office treatments can make one more sensitive to sun damage. Sun screen minimum of 30 SPF is agreed to be worn on a daily basis.
I understand there is a 48 hour cancelation policy. Missed/ late cancelations are charged in fullness. Lateness in excess of 15 minutes may forfeit your appointment.
I understand that if I remove my jewelry I will place it in my pocket or purse. MedEstheticsRX is not responsible for lost or misplaced items.
I certify that I have read and understand the above information, that I have been given the opportunity to discuss all my questions and have received satisfactory answers. I hereby consent to the in-office procedure. This Document supersedes any previous written or verbal disclosure.
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