Reemake Skin Care Medical Spa & Laser Clinic
Name: Please select 1-5 options that describe your skin concerns Fine Lines and WrinklesSensitivitySkin laxity/SlackeningPigmentationDehydrationRosaceaFine Lines and WrinklesSensitivitySkin laxity/SlackeningPigmentationDehydrationRosaceaAcneLarge PoresDrynessAdult AcneFrown Lines(glabeller)Crows Feet EyesOil ProductionLip LinesDullnessScarringHypopigmentationSpider Veins(telangiectasias)AcneLarge PoresDrynessAdult AcneFrown Lines (glabeller)Crows Feet EyesOil ProductionLip LinesDullnessScarringHypopigmentationSpider Veins(telangiectasias) MEDICAL HISTORY: check the boxes that apply to you AllergiesMetal plates. Pins, insertsSensitivityDental Work (metal Fillings)Sun SensitivityDiabetesSelf TannerMigraineTanning BedsSeizure disordersDirect Sunlight TanHormone ProblemsChlorine Water SwimmerMenopausalProne to Cold SoresMenstrual IrregularitiesExercise LevelSkin CancerAutoimmune DiseaseRecent Surgery SKIN TYPE: DryOilyCombinationNormalSensitiveDehydrated SKIN TREATMENT HISTORY: check the boxes that apply to you Chemical PeelsMicroneedlingDermaplaningBotox and FillersMicrodermabrasionLaser TreatmentsFacialsFacial Surgery Dermaplaning will exfoliate the superficial dead skin and remove the velours hair (peach fuzz), leaving my skin smoother, brighter, ingredients will penetrate deeper immediately after, and makeup application will appear flawless. I, , voluntarily consent to Reemake Studio’s skin consultants or partnering certified technicians to perform a dermaplaning treatment on my face; I understand the procedure as explained, the risks although rare, and the usual results. List current medications and supplements: I have disclosed all medications to the service provider. I have been made aware that Full Block Protection, summer and winter, will ensure a better result with treatment and my future skin health. Photos are taken for accurate record keeping purposes and showing progress to client and technician. Pre, post treatment, and ongoing maintenance has been thoroughly explained to me. Following instructions will minimize complications although rare. Slight redness, stinging, slight skin nicking, or darkening may occur and will subside in 2-7 days. I waive all claims, for injury, pain, and suffering, or other personal loss or damages that I have or may have in the future against, and release, and forever discharge Reemake Studio and staff, from all liability and all actions, causes of action suits, contracts, claims, and demands whatsoever which I may have against Reemake Studio staff or any officers, employees, technicians, and representatives of Reemake Studio. I am over 18 years and understand my consent is required before treatment. Client printed name and signature:
