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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 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

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599 Watervliet Shaker Rd
Latham, NY 12110
518-378-4763
clearsolutionsacne@gmail.com

Located inside Myo Massage.

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