Microcurrent Form Please fill out this form as fully as possible. Today's Date* MM slash DD slash YYYY Name* First Last Age* Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home or Cell Phone*Email Address* Please list any allergies you have:Please list all current medications, including oral and topical prescriptions and over the counter herbs, vitamins and supplements:These questions are relevant to your skin health and may be contraindications for treatment, please answer thoroughly.Are you pregnant or nursing? Yes No Do you have any active cancer? Yes No Do you wear contacts or glasses? Yes No Do you have any metal implants, including plates, screws or pins? Yes No Do you have any metal piercings? Yes No Do you use a pacemaker? Yes No Do you have heart problems? Yes No Do you have high or low blood pressure? Yes No Do you have braces, metal fillings or other dental implants? Yes No Do you currently have a cold or flu? Yes No Do you have an autoimmune disorder (including HIV) or connective tissue disease? Yes No Do you use Retin-A, Accutane or any other prescribed topical vitamin A derivative? Yes No Have you ever had Botox, Juvederm or any other injectable? Yes No Please give any details or adverse reactions that apply to any above.Have you ever had any of these conditions?Check all that apply. Acne/rosacea Bell’s palsy Cold sores Diabetes Embolism Epilepsy Light sensitivity Melanoma Migraines Open wounds Sensitive skin Stroke/TIA Skin inflammation/disorders Thyroid conditions Any other health conditions not listed?Is there anything else we should know about?Although every precaution will be taken to ensure your safety and wellbeing before, during and after your microcurrent treatment, please be aware of the following information and possible risks.By marking 'Yes' you acknowledge your understanding.I understand that the use of Botox, Juvederm, Restylane, and any other injectable must be disclosed prior to treatment.* Yes I understand that microcurrent treatments involve conducting mild electrical currents through the body, and that this brings some inherent risk.* Yes I understand that reactions are rare, but may include nausea, dizziness, weakness, and possible skin reactions including redness and/or other irritations.* Yes I understand that some clients report slight tingling sensations, flashing of the optic nerve, and/or a metallic taste in the mouth during the procedure.* Yes I understand that while the goal of this treatment is to improve the vitality of the skin, no specific guarantees of the result can or have been made.* Yes I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History.* Yes I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.* Yes I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.* Yes I consent to “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.* Yes I understand that if I have any concerns, I will address these with my skin care specialist. I give permission to my skin care specialist to perform the microcurrent procedure we have discussed, and will hold him/her and his/her staff, and TAMA Research, Inc., harmless and nameless from any liability that may result from this treatment. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care specialist immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the skin care specialist, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.* Yes Book Online Buy Gift Certificates Get in touch599 Watervliet Shaker Rd Latham, NY 12110 518-378-4763 email@example.com FollowFollow Located inside Myo Massage.