Consulation Form

Date

Day

Month

Year

First name

Last name

Address

Phone

Birthday

Day

Month

Year

Your Skin

Your Skin Type

Normal

Dry

Oily

Combination

Your Health

1. Within the last year, have you been under a dermatologist's or another physician’s care?

Yes (if yes, please give the details below)

If yes, please provide details below:

3. Any other medical conditions/ skin conditions/ allergies?

Yes (if yes, please give the details below)

If yes, please provide details below:

4. Do you have reduced physical mobility?

Yes

5. Do you have metal implant(s)/ a pacemaker/body piercing(s)?

Yes

6. Have you had any Botox or fillers in the last 4 days?

Yes

7. Have you had a tattoo in the last 6 weeks?

Yes

8. Have you had microblading in the last 6 weeks?

Yes

9. Are you pregnant?

Yes (if yes, please give the details below)

If yes, please provide details below:

I confirm (to the best of my knowledge) that the answers I have given are correct, and that I have not withheld any information that may be relevant to my treatment. If I required approval from my doctor, I have provided my therapist with my doctor’s letter.

Signature

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Electrical Facial / Body Treatments

Cosmetic Electrotherapy is a range of beauty treatments that use low electric currents that pass through the skin to produce several therapeutic effects and take professional facials to even deeper layers.

Please read and acknowledge each statement

I have read the Electrical Treatment information and have had an opportunity to ask questions about the procedures and treatment

I authorize the Charm Spa therapist to perform Electrical Beauty Treatment on me

Possible contraindications:

Cancer; Epilepsy; Diabetes; Pregnancy and breastfeeding; Phlebitis and Thrombosis; Hemophilia (condition of diminished/absent blood clotting factors); Pacemakers or metal implants; Inflammatory diseases; Acute infectious diseases and fever; Disfunction or disorders of the nervous system (such as multiple sclerosis, strokes, Parkinson's disease, etc); Sunburn or Windburn; Swollen or infected tonsils; Thyroid conditions; Patient under medical care for an existing or suspected condition or disease; Asthma; Herpes, open wounds; Mental disorders; Drink or drugs; Infected acne; Cuts and abrasions; Hypersensitive skin; Exessive metal fillings or bridgework; Retin A, retinol less then 3 days before treatment. Autoimmune diseases, Acutane (if used within the last year).

Please provide details of any contraindications you have, and discuss this with your therapist before the treatment.

I understand and will discuss my contraindications with the therapist.

I understand that:

Every person is unique and skin conditions and results may vary, so it is tough to guarantee a specific number of treatments needed.

Common side effects such as a slight redness usually subside within a few hours after the treatment.

Very rarely, some types of allergic reactions, pigmentations, moles, skin lightening, or darkening can occur and may resolve, but can be permanent. There may be risks not yet known at this time.

I fully understand this (Provide signature below)

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