Diarrhea/constipation
� Yes
� NoEczema
� Yes� No Where _________________________
Epilepsy
� Yes
� NoHay Fever� Yes
�NoHeadaches
� Yes
� No
How often _____________________
Heart Disease/Conditions
� Yes
� No
What___________________________
Hepatitis� Yes
� NoHIV/AIDS� Yes
� NoInfections
� Yes
� NoLupus
� Yes
� No
Menopausal
� Yes
� No
Metal Implants
� Yes
� NoPace Maker
� YesINFORMED CONSENT� No FOR CHEMICAL PEEL
Phlebitis
� Yes
� No
Serious Injury
� Yes
� NoWhat __________________________
Sleep problems
� Yes
� NoThyroid
� High� Low
� NormalInitial on lineI, _______________________________________,
give permission to my skin care professional,
Varicose Veins
� Yes
� No
____________________________________,
Do you smoke?
� Yes� No to perform the Circadia chemical peel treatment:
Do you wear contact lenses?
� Yes
� No

� Lactic

23. Have you ever had a reaction to� Alpha/Beta � Jessner’s� Cosmetics

� Metals� DermaFrost Salicylic
� Medication

� Food� MandeliClear� Fragrance

Airborne� Other
1. �I agree
to particles?
complete a Confidential
SkinExplain_____________________________
Health Questionnaire. I agree to complete andbe truthful about my physical conditions,pregnancy, �medications
that I may be taking,
24. FOR WOMEN: Oral contraceptives?
� Yes
Noand mycurrent
skin care regimen.
I am also aware thatmy lifestyle, which if it includes
Are you pregnant or tryingto getpregnant?
� Yes
� NoAre you taking hormone
replacement?
� Yes beds, excessive alcohol� Nosmoking,outdoor exposure, tanningconsumption and/or
Do you experience hormone
imbalances?
� Yes� Nodiminish the effectiveness andrecreationaluse of controlled substances,
will effect andwith� Electric shaver?
� Razor?
25. FOR MEN: Do you shave
resultof the treatment.
Do you experience skin breakouts?
Do you have ingrown hair?

LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

� Yes
� Yes

� No� No

2. I have disclosed to my skin care professional/esthetician any surgical procedures, laser
treatments or facial procedures that I have had or intend on having in the future.

Is your stress level
� High� Medium� Low
Do you normally sleep well?
� Yes
� No
3. I am not presently
pregnant or�lactating
Do you regularly exercise?
� YesNo
Do you have food intolerances?
� Yes
� No
What?____________________________
I havediet?
not had �anyor radiation treatments
Do you follow any4.special
Yesrecent chemotherapy
� No
How many glasses of water do you consume daily? ______How many cups of5.caffeine-type
beverage(coffee,drinks) do you
consumedaily?
I have not recently
waxedor tea,usedsoft
a depilatory(suchas Nair)on the area being treated� 1-3 cups
� 4 or more
today. I do not have a history of keloid scarring, diabetes, any autoimmune disease,In our treatment program, it may be necessary to recommend alterations to or additions in your home
active herpes blisters or cold sores.
care regimen; would that be OK with you?
� Yes� No

6. I have not had any other peel treatment of any kind within 14 days of treatment. IYour practitioner will recommend the appropriate schedule for future facial treatments or physician referral
understand I cannot have another treatment within 14 days of this treatment, whether thein order to achieve your skin improvement goals.

treatment is performed at this location or any other location.

7. I agree to refrain from excessive sun exposure or the use of a tanning bed while I am
INFORMED CONSENT RELEASE
undergoing treatment and during the 14 days following the end of the treatment.

I _________________________________,
dothatfully sununderstandall isthequestionswhileabove
andundergoinghave answeredthem and that the8. I understandexposureprohibited
I amtreatment
all correctly and honestly. I understand that the services offered are not a substitute for medical care. I
ofprofessional
Circadia LightDay Broad Spectrum
37 isinmandatory.
understand that the skinuse
carewill completely
inform me Sunscreenof what to SPF
expectthe course oftreatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that
9. I understandtheage,purposeof this peelingprocedure
is totoexfoliate
outer surface of myindividual results are dependent
upon myskin condition,and lifestyle.
I agree
activelythe
participate
Some ofthehomebenefits
lesseningofbestpigmentation,
reduction
appearance ofin following appointmentskin.
schedules
andcareinclude
proceduresto theof my ability,
so that Iinmay

fine lines and wrinkles, and control of certain conditions such as acne or occasional
breakout.

Circadia by Dr. Pugliese, Inc.

87

Copyright 2018

Diarrhea/constipation
� Yes� NoEczema
� Yes� No Where _________________________
Epilepsy� Yes
� No
10. I understandthat the following conditions
preclude me from having this treatment at thisHay Fever� Yes
�Notime and verify
apply
me at this time.
Headaches� Yesthat none of these conditions
� NoHow
oftento_____________________
Heart Disease/Conditions
� Yes
� No
What___________________________
Hepatitis
� Yes
� No_______ Allergic
to aspirin or any salicylic
sensitivity (DermaFrost contains salicylic acid).
HIV/AIDS
Yes on areas to be treated� No_______ Broken�skinInfections
� Yes
� No_______ Sunburnor windburn skin
LupusYes� No lesions_______ Visible�inflammatory
or inflammatory
Menopausal
� peels
Yes within eight weeks
� No_______ RecentMetal Implants
�Yes�
No_______ Herpes virus (cold sores) on mouth
Pace Maker�Yes�
No_______ Use of Accutane® within the past 12 months
Phlebitis
Yes_______ Use of�glycolicacid products � No
Serious Injury�Yes� No (Vitamin
What _________________________________ Use of Retin-A®, Renova®, retinoidsA) in the last 4 weeks
Sleep problems
� Yes
� NoThyroid
� High� Low
� Normal
11. My expectations are realistic and I understand that the results are not guaranteed andVaricose Veins
� Yes
� No
that for maximum results, more than one application may be necessary. The rate ofDo you smoke?
� Yes
� No
improvement
depends on my skin�type,Do you wear contact lenses?
� Yes
No condition, my age, degree of sun damage, orpigmentation levels.
23. Have you ever had a reaction to� Cosmetics
� Metals� Medication
� Food12.
Iunderstandthecostoftreatment
andthefeestructure
has
been
explained to me.
� Fragrance� Airborne particles?
� Other Explain_____________________________
24. FOR WOMEN: Oral
� Yes are very rare, sometimes
� No
13. I contraceptives?
understand that although complications
they may occur and
Are you pregnant or
tryingtogetpregnant?
�Yes�Nothat prompt treatment is necessary. In the event of any complication,
I will immediately
Are you taking hormone replacement?
Yes� Nocontact the skin care professional �whoperformed the treatment.
Do you experience hormone imbalances?
� Yes
� No
� Electric shaver?
� Razor?
25. FOR MEN: Do you shave with
14. I understand of the possibility of peeling, flaking, hyperpigmentation and excessive
Do you experience skin breakouts?
� Yes� Nodryness. I agree to use the products specifically recommended by my skin care
Do you have ingrown hair?
� Yes
� No
professional/esthetician and including a sunscreen.
LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

15. I understand that every precaution will be taken to minimize or eliminate negative
Is your stress level reactions such as blisters,
� High redness, �� LoworMedium
irritation.
Do you normally sleep well?
� Yes
� No
Do you regularly
� Yes
� No
16.exercise?
I understand that mypractitioner will
recommend home care products to work in tandem
Do you have foodwith
intolerances?
�Yes� No to follow
What?____________________________
the in-clinic treatment. I am willingrecommendations by my skin care
Do you follow anyprofessional
special diet?for home
� Yes
�
Nocare.
How many glasses of water do you consume daily? ______How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
� 1-3 cups
� 4 or more
17.program,
I consentit tothebetakingof photographs
to monitor
treatment
effect andresults
if desired by
In our treatmentmaynecessary
to recommend
alterations
to or additions
in yourhome
mytherapist.
care regimen; would that be OK with you?
� Yes
� NoINFORMED CONSENTYour practitioner will recommend the appropriate schedule for future facial treatments or physician referralin order to achieve your skin improvement goals.
In the event of any questions or concerns, I will consult my skin care professional immediately. I
understand the potential risks and complications and I have chosen to proceed with thetreatment
INFORMED CONSENTRELEASE after careful consideration of both known and unknown risks, complications, andlimitations. I will hold the skin care professional and staff harmless from any liability that may
result from this treatment.
I _________________________________, do fully understand all the questions above and have answered them
I agree that
this constitutes
full disclosure,and thatit supersedes
any
all correctly and honestly.
I understandthat theservices offered
are nota substituteforprevious
medical verbal
care. orI written
disclosures.
I
certify
thatI
have
read,andfully
understandtheaboveparagraphs
andunderstand that the skin care professional will completely inform me of what to expect in the course of that I
had sufficient
opportunity
discussion
to havenecessary.
any questions
answered.
treatment and willhave
recommend
adjustments
to my for
regimen
if deemed
I alsoam aware that
individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate
in following appointment
schedules________________________________________and home care procedures to the best of
my__________________________
ability, so that I may
Client Signature
Date
Skin Care Professional ___________________________________ Date _________________________

Circadia by Dr. Pugliese, Inc.

88

Copyright 2018