Osmosis Consent Form Please fill out the form as completely as possible. Today's Date* MM slash DD slash YYYY Name* First Last Age* Date of Birth* Gender* Female Male Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address* Preferred Contact Number*May we leave a message if we do not reach you personally?* Yes No What are your top 3 concerns at this time?*medical historyPregnant? Yes No Maybe N/A Breastfeeding? Yes No N/A Do you smoke? Yes No Health conditions:Past Surgeries:Have you ever been diagnosed with Cancer? Yes No Date of last treatment: Current Medications:Prescription Topicals:Allergies (include aspirin/iodine):Previous TreatmentsPlease give the last treatment date and any complications experienced for EACH of the following.Facials: Microdermabrasion: Chemical Peels: Waxing: Tanning: Laser Therapy: Massage:Include preferred pressure (light, medium, deep) Skin ConditionsCheck all that apply past or present. Skin Infection Herpes (cold sores) Keloids/Excessive Scarring Sun Sensitivity Skin Cancer Poor Healing Tattoos/Permanent Makeup Easy Bruising Eczema Psoriasis Lymph Nodes Removed Diabetes Other Other What type of skin do you feel you have? Dry Oily Normal Combination Sensitive What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masks, sunscreens, etc.)Please be as detailed as possible.Check 'yes' to acknowledge your understandingI agree that the nature and purpose of the treatment has been explained to me and any questions I have regarding the treatment have been explained to my satisfaction.* Yes I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.* Yes I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.* Yes I do not have active cold sores.* Yes I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.* Yes I understand that it is recommended prior to having a facial infusion to not have used Retin A for 72 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment.* Yes I consent to and authorize treatment and that the information is accurate to the best of my knowledge.*Please enter your FULL NAME to be used as your electronic signature. Book Online Buy Gift Certificates Get in touch599 Watervliet Shaker Rd Latham, NY 12110 518-378-4763 firstname.lastname@example.org FollowFollow Located inside Myo Massage.