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 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 history
Pregnant?
- 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 Treatments
Please 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 Conditions
Check 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 understanding
I 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.

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

Located inside Myo Massage.

Osmosis Consent Form

medical history

Previous Treatments

Check 'yes' to acknowledge your understanding

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