Open
Doctor's Search
Search Team Members by name and also by section
Search
Call us now!
248-426-7200
Modern Medicine; Old Fashioned Care
Toggle menu
Skip to content
PrimeCare of Michigan
>
Spa Consent
Spa Consent
Facial Consent
Name
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Phone
(Required)
Assigned Sex at Birth
Female
Male
Other
Email
Occupation
How did you hear about us?
Facebook/Instagram
Online Search
Referral
Who referred you?
Emergency Contact
First
Last
Medical History
Have you seen a dermatologist in the past year?
(Required)
No
Yes
What is your dermatologist's name and contact information?
Have you had recent surgery or plastic surgery?
(Required)
No
Yes
Please explain what surgery you had performed?
Have you ever had any of the following?
(Required)
Hormone Imbalance
Cancer
Skin disease/ lesions
Systemic disease
High blood pressure
Diabetes
Arthritis
Auto-immune disease
Asthma
Epilepsy/ Seizures
Frequent Sores
Herpes
HIV/AIDS
Hepatitis
Lupus
Depression/Anxiety
Headaches/Migraines
Sunburn
Eczema
Hemophilia
Psoriasis
Heart Problems
Phlebitis, Blood clots, Poor circulation
Moles
Thyroid Condition
Neck or Spinal Injury
Any active infection
Keloid Scarring
Fibromyalgia
Head or neck pain
Other
Please specify other conditions
Do you have any allergies to the following? (select none if you do not)
(Required)
Aspirin
Latex
Fruit
Lidocaine
Fragrances/Essential Oils
Tree Nuts
Dairy
Sunscreen
Pollen
None
Other
Please list other allergies
(Required)
Please list any medications or supplements you are taking:
Do you (check any that apply)?
Smoke
Consume Alcohol
Use any recreational drugs
Consume Caffeine
Consume water regularly
Exercise regularly
Follow a restricted diet
Have a pacemaker
Have any metal implants
Wear contact lenses or glasses
Frequent tanning booths
None
Have you experienced clausterphobia?
No
Yes
Are you pregnant or breastfeeding?
(Required)
No
Yes
Are you taking birth control or hormone replacement?
(Required)
No
Yes
Your Skin
Have you had a facial treatment before?
No
Yes
When was your last treatment?
(Required)
Are you currently using any products that contain or are you taking any of the following?
Acne Medication
Prescribed topical cream
Retinol/Vitamin A derivative products
Products containing Hydroquinone or Alpha Hydroxy
AHA’s (Glycolic Acid, Lactic Acid)
BHA (Salicylic acid)
None
Have you received any of these skin care treatments?
(Required)
Chemical peel
Microdermabrasion
Dermaplaning
Microneedling
Facial Ultrasound
Laser Hair Removal
Laser Treatments
Waxing
None
How long ago did you perform the above checked item?
Within the past 7-10 days
Within the past month
Within the past 2-3 months
Have you ever had an adverse reaction after using any skin care product?
No
Yes
What was your reaction? Check all that apply
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Which product or brands cause the reaction?
Have you had botox or injectibles?
No
Yes
Date of last treatment for botox or injectible:
MM slash DD slash YYYY
What do you consider your skin type?
Normal (no blemishes, fine pores, smooth texture)
Oily (enlarged pores, excess oil)
Acne (cystic or nodule)
Dry (dull, visible lines/ wrinkles, feels tight)
Aging (dry, very visible deep lines/ wrinkles)
Combination (oily and dry patches, oily t-zone, hormonal acne)
Sensitive (reactive to fragrance, often irritated)
Not sure
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin)
No
Yes
Do you have frequent breakouts?
No
Yes
What skin care products do you currently use?
Soap
Cleanser
Tonor
Exfoliator or scrub
Mask
Moisturizer
Sunscreen
None
What is your daily skin care regimen?
Do you use sunscren?
Always
Often
Sometimes
Never
What are your specific concerns at this time regarding your skin?
What is your skin care goal?
Indicate what services or areas you are interested in (check all that apply):
Minimize/ Remove Sun Spots
Melasma
Wrinkle reduction
Acne treatment
Microneedling
Rosacea
General skin care
Consent
I agree to the privacy policy.
I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure.
I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.
I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.
I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjust
accordingly.
I understand that I or the esthetician may terminate the session at any
time.
I have been given a chance to ask questions about the session
and my questions have been answered.
I consent (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. I give consent for all future treatments.
I, therefore, release PrimeCare Spa and its staff of from all and any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Signature
(Required)
Search
+
