Oxygen Facials and LED Light Therapy Consent

New Client Appointment Checklist

Complete and submit form below

Please arrive at least 15 minutes early for your first appointment.

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These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

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Please understand the importance of keeping your appointments. We do have a 48 hour new client/24 hour regular client appointment cancellation policy that is strictly enforced.

New Client Form

Aesthetic Portable Oxygen Infusion System Skin Awareness + Contra Indications

• Pregnancy

• Breast Feeding

• Accutane- (should be a minimum of 8 months), when in doubt consult a physician for approval.

• Do not combine with TCA< Jessner, or Salicylic Acid Peels Sunburn

• Rosacea Advanced Stages - III

• Cancer/Skin Cancers/Open Lesions

Precautions

• Alpha Hydroxy (Glycolic, Mandelic, Azelaic, Lactic, Citric) skin must be free of all sensitivities before applying Skin for Life oxygen infusion therapy.

• Retinoid (Retin A, Tazorac, Differin, and any other vitamin A derivative) Have client/patient discontinue for 3 days before performing an oxygen infusion therapy.

• Skin sensitivity

• Contacts - Please have client/patient remove contacts before oxygen procedure.

• Under the care of a physician - general for all procedures administered.

Informed Consent

Name: *

Birthdate: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone Number: *

Work Phone Number:

Physician:

Physician Phone Number:

Referred by:

Are you currently a client of The Well of Life Center? *

If yes, who is your Clinician?

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

What is the reason for your visit today?

Are you under the care of a physician, including dermatologist? *

If yes, please state the reason:

Are you pregnant? *

Are you planning to become pregnant? *

Do you smoke? *

Please choose the one that best describes your daily stress level: *

High
Medium
Low

Do you have metal in your body? Such as dental work, pins, plates, stints, etc. Be specific.

Do you have allergies? *

Please list ALL medications:

What type of exfoliation skin products do you use? Glycolic, scrubs, retin A, or any vitamin A derivatives.

Do you use sunscreen? *

What SPF?

Click below to agree and sign by typing your name: *

I understand the information I have given is to aid the skin therapist and is not a substitute for medical care and I understand the questions and I have answered them honestly and accurately.

Electronic Signature: *

Sign by typing your full name in the box above.

Today's Date: *

Spa Informed Consent

• Do not wear contact lenses during treatment sessions - they may be placed back in after treatment.

• Do not use glycolic. AHA’s. Or any retinol products 48 hours before or after treatment.

• You must not be currently taking Accutane -- nor have you taken Accutane for the previous 8 months to 1 year.

• No suntan beds for 2 weeks post treatment (recommended self-tanners for a healthy lifestyle change).

• Physical sunscreen of at least SPF 30 to be applied and reapplied during sun exposure.

Check the box to agree:

I am committed to following post treatment care given to me by my Well Spa Esthetician to ensure the best possible results.
I have given all medical information to the best of my knowledge to prevent any contraindications to procedures.
I have a history or cold sores, fever blisters, and/or shingles.
I am using Retin A, Tretinoic Acid, Differin, Glycolic Acid, Accutane, or any other Vitamin A derivative topical creams and/or ointments.
I have not used any performance agents within the last 5-7 days, knowing that this a contraindication for having procedures performed.
I am committed to avoiding the sun and/or tanning facilities for the recommended time suggested by my Well Spa Esthetician.