FACIAL CONSULTATION FoRM


Osmosis Treatment Consent

I agree that the nature and purpose of the treatment has been explained to me and any questions I have regarding the treatment have been explained to my satisfaction.

I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.

I understand that possible side effects include but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, or cold sores, or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.

I do not have active cold sores.

I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.

I understand that it is recommended prior to having a facial infusion to not have used Retin A for 72 hours, Accutane for 6 months, or have waxed 24 hours prior to receiving treatment.

Name *
Name
DOB *
DOB
Preferred Phone Number *
Preferred Phone Number
Address *
Address
Are you any of the following? *
If you answered YES to the previous question, when was your last treatment?
If you answered YES to the previous question, when was your last treatment?
Previous Treatments
What type of skin do you have? *
Skin Conditions
What is your skincare routine? Do you use any of these?
SIGNATURE
By filling your name in here, you have officially signed this document. *
By filling your name in here, you have officially signed this document.