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Meso Therapy

We are excited you have chosen one of our Meso Therapy Facials. Please take a moment to fill out the consent form below.

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Phone

Last Name

Date of Birth

Address

ABSOLUTE CONTRAINDICATIONS (Please check all that apply)

Accutane of other similar medicatoion (in the past year)

Autoimmune disease

Active infection in the treatment area

Melanoma or lesions suspected of malignancy

Active Sunburn

Pregnant or Breastfeeding

Breast feeding (medical-legal

Epilepsy contraindicated for LED light therapy

None

RELATIVE CONTRAINDICATIONS

Anticoagulants Therapy (use lower settings)

Very thin skin

Other Aesthetic Treatments: Botox: wait 5-7days: Fillers: wait 7-10 days: Peels: wait 30 days

Laser Treatments: wait until leisons heal & swelling & redness is resolved

None

OTHER CONCERNS

Keloids: avoid direct contact

Rosacea, Telangiectasia (use lower vacuum)

Unrealistic expectations

Do you have any allergies to latex?

Are you allergic to metals? (Nickle)

Do you have any problems healing from small wounds?

Do you have Active Acne?

Do you have routinely use Retin A, Glycolie or other exfoliating products?

Have you had any chemical peels within 2 weeks?

None

If you answered YES to any of the above questions please explain:

* Please list any allergies:

Client Consent Form (Initial each acknowledgement line below)

I acknowledge that my skin experience temporary irritation, tightness or redness which usually dissipates within 72 hours d epending on skin sensitivity. (INITAL) _____

I acknowledge that if I fail to use a minimal sunscreen (SPF 30) and follow the direction for use, I am more susceptible to sunburn, sun damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm. (INITAL) _______

I have disclosed my history of allergies above and I acknowledge that if I am allergic to one or more of the ingredients. (INITAL) _______

I accept terms & conditionsI hear by agree to have the treatment performed and agree to follow all pre & post treatment instructions. (INITAL) ______

I acknowledge that I have answered all questions truthfully and completely. (INITAL)

I release Xpose Salon & Lounge Inc. from any and all liability associated with any injuries and/or current future conditions res ulting from the skincare procedures or products. (INITAL)

I consent to the use of my before, during and after facial procedure photography for education, promotion/ advertising purposes. My name will not be used to identify these photogprahs withing my written approval. (INITAL) _____

I accept terms & conditions

Your Signature

Today's Date

Thanks for submitting!

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