Please complete the forms below before your appointment. If you are unable, please make sure to arrive 15 minutes early to your appointment to complete in-office.

AquafirmeXS Medical Grade Facial Intake Form

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

Birth Sex *

Male

Female

Unknown

Date of Birth *

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone # *

(###)

###

####

Emergency Contact Relationship to Client *

Please select the areas/concerns in need of addressing *

Fine lines and wrinkles

Acne scars

Acne

Aging or Sunspots

Lagre Pores

Uneven Skin Tone

I currently have or have a history of the following: *

Please select all that apply

Actinic (solar) keratosis

Active acne

Collagen vascular disease

Cardiac abnormalities

Diabetes

Eczema

Psoriasis

Immunosuppressive therapy

Contact dermatitis

Raised moles in the treatment areas

Rosacea in the treatment areas

Active bacterial or fungal infections in the treatment areas

Active viral herpes (zoster/shingles or cold sores) in the treatment areas

Anticoagulant use (blood thinners)

Scleroderma

Wound healing deficiencies

Current Smoker

None of the Above

Current medications

Current supplements

Allergies

Date of appointment *

YYYY

Time of Appointment *

Hour

Minute

Second

Thank you!

AquafirmeXS Medical Grade Facial Informed Consent

Name *

First Name

Last Name

Email *

Phone *

(###)

###

####

It is our duty to inform you of your rights as a patient or client. Below is a list of expected and possible outcomes: *

- Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 24 hours depending on skin sensitivity. - You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours. - Client experiences may vary. Some clients may experience a delayed onset of these symptoms. - You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results. - The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 25 sunscreen.

I understand

The following apply to me: *

I am currently using Accutane or other similar medication .

I am currently under the care for an autoimmune disease, HIV, lupus, hepatitis, scleroderma n 2

I currently have an active infection in the treatment area.

I am currently under the care for melanoma or other lesions suspected of malignancy.

I have an active sunburn.

I am currently pregnant.

I am currently breastfeeding.

I am currently being treated for epilepsy or other seizure disorder.

I have Metal implants, pacemakers, defibrillators, nerve stimulators or any embedded electronic devices.

I have received filler injections less than 4 weeks ago. It is recommended to wait at least 4 weeks after injectables.

I am currently on anticoagulant therapy (eg. baby aspirin, Eliquiss, Xarelto, etc)

I have very thin skin.

I have received other aesthetic treatments such as mesotherapy, peeling, resurfacing, injections on the area of cosmetic treatment less than two weeks ago.

I have unrealistic expectations.

None of the above.

Thank you!