Thank you for scheduling your Gold Skin appointment!Please take a few moments to fill out this form prior to your appointment. Date MM DD YYYY Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Email * Phone Number (###) ### #### What are your specific skin goals you are looking to achieve with GoldSkin RF Microneedling? * Have you ever had a Microneedling or Fractional Radio Frequency treatment before? (They are commonly known as Vivace or Morpheus) * Yes No If "yes", when was service received? MM DD YYYY Have you ever had a skin reaction to Vitamin C or anny Vitamin C deritative * you will be encouraged to use a Vitamin C serum 2 weeks post procedure. If you are allergic, please notify esthetician so a replacement serum can be ordered. Yes No Do you have any skin or food allergies? * If "yes" please describe in detail the reaction and the allergy source It is important that you do not receive any form of chemical peel, laser, facial surgery, microdermabrasion, fillers or any type of injectable one month prior to service * Have you had any of the above in the past month? yes no unsure Do you understand that you will not be able to wear makeup, sunscreen, use heavy soaps or lotions, and no retinol or retinoid for a full 48 hours post procedure? * This can cause a serious reaction and hinder results. Yes No Please list any blood thinners you haave taken * Blood thinners MUST be stopped 72 hours prior to service. Please list all medications (including supplements) you are taking currently. If none write N/A * Are you pregnant or trying to become pregnant? * Yes No Any menopause problems? * Yes No Are you undergoing any hormone replacement therapy? * Yes No Would you like a 5% lidocaine numbing cream prior to service? * If yes, please show up 15 min. early to allow numbing cream to set. Please initial that you understand the following: Drinking alcohol, getting the procedure while feeling ill, and working out, during treatment and 48 hours post treatment is not encouraged as it takes away from your immune system's response to healing your skin. Your results WILL be hindered if you chose to do any of these things. * Would you like to schedule an extra 15 mintues post treatment with the Red Light Mask to enhance healing results and stimulate your skin's repair for an additional $25? * yes no Please initial that you understand the following: If you have received cosmetic fillers or injectables within the last month and do not reschedule your appointment, you will be unable to receive this service and you will not be refunded for the service amount. Your fillers/injectables can be moved around with a Goldskin Facial. * Please initial that you assume all risk and release all liability when receiving a facial service? * Please initial that you understand that failure to answer all questions of this form completely and truthfully can prevent services from being redered? Please initial that you understand the following: if you do not cancel and or reschedule your appointment within 24 hours of your appointment time you will be charged a non-refundable $50 fee for the time slot that was reserved especially for you? * please initial below that you understand the following: This procedure, like any other is not 100% guarenteed to yeild results. It is backed by science, however, everyone's skin reacts and heals differently,. No refunds will be given after service has been rendered. * Please initial that you understand the following: If you fail to call or show for your appointment, you will be charged the full service amount without refeund. Photo Release * Do you consent to before and after photos/videos if applicable? Yes No Late and Early Appointment Policy: * The time you book your appointment is especially reserved for you. Please note, the service being rendered begins at the time of appointment. Depending on service being rendered, The service time slot includes check in, check out and dress time. If you are early for your appointment and can be seen at arrival, your service time begins when brought to treatment room. If you are late for your appointment, your service time begins at your originally scheduled time. Please initial below acknowledging the above policy. Thank you! Please contact Tara Randall with any questions or concerns prior to your appointment time.
