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
� Yes
� No
INFORMEDCONSENT FOR OXYGEN
Phlebitis� Yes� No RX AND ENZYMES TREATMENT
Serious Injury
� Yes
� No
What __________________________
Initial problems
on lineSleep
� Yes
� NoThyroid
� High� Low
� NormalI, ____________________________________________,
give permission to my skin care professional,
Varicose Veins
� Yes
� NoDo you smoke?
� Yes
� No
_______________________________________________________,
to perform the Circadia treatment:
Do you wear contact lenses?
� Yes
� No

� Oxygen
Rxto
Treatment
Enzyme23. Have you ever hada reaction
� Cosmetics� Cocoa
� Metals� Fragrance� Airborne particles?

� Raspberry Enzyme
� Medication
� Food � Zymase Enzyme

� Other Explain_____________________________

24. FOR WOMEN: Oral1.contraceptives?
� YesSkin Health Questionnaire.
� No
I agree to complete a Confidential
I agree to complete andAre you pregnant or trying
togetpregnant?
�Yes�Nobe truthful about my physical conditions, pregnancy, medications
that I may be taking,
Are you taking hormone
replacement?
� YesI am also aware that
� Noandmy current skin care regimen.
my lifestyle, which if it includes
Do you experience hormone imbalances?
� Yes
� No
smoking, outdoor exposure, tanningbeds, excessive alcohol
consumption and/or� Electric shaver?
� Razor?
25. FOR MEN: Do you shave withrecreational use of controlled substances, will effect and diminish the effectiveness andDo you experience skin breakouts?
� Yes
� No
result of the treatment.
Do you have ingrown hair?
� Yes
� No
LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

2. I have disclosed to my skin care professional any surgical procedures, laser treatments, orIs your stress level
� High� Medium� Lowthat I have had
Do you normally sleepfacial
well?procedures
� Yes
� Noor intend on having in the future.
Do you regularly exercise?
� Yes
� No
3.intolerances?
I am not presently
pregnant or�lactating
Do you have food
� Yes
NoWhat?____________________________
Do you follow any special diet?
� Yes
� No
How many glasses4.of wateryouconsume
daily?chemotherapy______I havedo
nothadany recent
or radiation treatments
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
� 1-3 cups
� 4 or more
5. I have not recently waxed or used a depilatory (such as Nair) on the area being treated
In our treatment program, it may be necessary to recommend alterations to or additions in your home
today.
dowithnot you?
have a history ofkeloid scarring,
diabetes, any autoimmune disease,care regimen; would thatbe IOK
� Yes
� No

active herpes blisters or cold sores.

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral
6. skin
I understandthatI should not have a treatment if I intend to be in the sun or use ain order to achieve yourimprovement
goals.

tanning bed and will refrain from excessive sun exposure and the use of a tanning bed
while I am undergoing treatment.

INFORMED CONSENT RELEASE

7. I have disclosed to my skin care professional any treatments of any kind that I havereceived within 14 days of this treatment whether the treatment was performed at thisI _________________________________, do fully understand all the questions above and have answered themor anythat
otherlocation.
all correctly and honestly.location
I understandtheservices offered are not a substitute for medical care. I

understand that the skin care professional will completely inform me of what to expect in the course of
8. I understandthat althoughcomplications
arenecessary.
very rare, sometimes
they maytreatment and will recommend
adjustments
to my regimen
if deemed
I also am awarethat occur andindividual results are dependent
upon
myage,
skincondition,andlifestyle.
Iagreetoactively
participate
that prompt treatment is necessary. In the event of any complication, I will immediately
in following appointment contact
schedules
andprocedures
the best ofability, so that I may
theskinhomecare care
professional
whoto
performed
themytreatment.

Circadia by Dr. Pugliese, Inc.
Circadia by Dr. Pugliese, Inc.

91

Copyright 2018
Copyright 2013

Diarrhea/constipation
� Yes
� NoEczema
� Yes� No Where _________________________
9. I understand that the following conditions preclude me from having this treatment at thisEpilepsy
� Yes
� Notime and verify
conditions apply to me at this time.
Hay Fever� Yesthat none of these �NoHeadaches
� Yes
� No
How often ___________________________ Allergic�toYes
citric fruits (oranges, �limes,lemons)Heart Disease/Conditions
No grapefruit,
What_________________________________ Allergic�toYes
cocoa, chocolate, and/orHepatitis
� No raspberry
HIV/AIDS� No______ Allergic�toYes
pineapple and/or papayaInfections
� toNoanything______ History �ofYes
being “highly allergic”
Lupus
� Yes
� No
______ Pregnant
or lactating
Menopausal
Yesof antibiotics (topical� No______ Current�useor systemic)
Metal Implants�Yes�______ Use of Accutane® within the pastNo
12-months
Pace Maker
� Yes
Nolast 12-weeks______ Laser resurfacing
surgery within�thePhlebitis� Yes acid products � No______ Using glycolic
Serious Injury
�Yes� No(Vitamin
What ________________________________ Use of Retin-A®,
Renova®, retinoidsA) in the last 4-weeks
Sleep problems ______ Broken �Yes�
NoSkin on areas to be treatedThyroid� High� Lowlesions
� Normal______ Visible inflammation
or inflammatory
Varicose Veins
� Yes
� No______ Recent peels within four weeks
Do you smoke?
� Yes
� No______ Herpes virus (cold sores) on mouth
Do you wear contact lenses?
� Yes
� No______ Laser Hair Removal within 6 weeks
23. Have you ever______
had aCurrently
reaction to� Cosmetics
� Metals� Medicationundergoing
chemotherapy
or radiation
treatments � Food
� Fragrance� Airborne particles?

� Other Explain_____________________________

24. FOR WOMEN: Oral contraceptives?
� Yes
� No
Are you pregnant
ortrying
togetpregnant?
�Yes�
10. I understand the cost of the treatment and the fee structureNo
has been explained to me.
Are you taking hormone replacement?
� Yes
� No
Do you experience hormone imbalances?
� Yes� Noshavewith�
Electricshaver?
� Razor?
25. FOR MEN: Do you
11. My expectations are realistic and I understand that the results
are not guaranteed andDo you experience skin breakouts?
� Yes
� No
that for maximum results, more than one application may be necessary. The rate ofDo you have ingrown hair?
� Yes
� No
improvement depends on my skin type, condition, my age, degree of sun damage, orpigmentation levels.
LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

Is your stress level
� High� Medium� Lowcare products to work in
12. I understand that mypractitioner will
recommend home
Do you normally sleepwell?
�Yes
�
No
tandem with the in-clinic treatment. I am willing to follow recommendations by my skin
Do you regularly exercise?
� Yes� Nocare professional forhome care, includinga sunscreen.
Do you have food intolerances?
� Yes
� NoWhat?____________________________
Do you follow any special diet?
� Yes
� No
How many glasses of water do you consume daily? ______
13. I consent to the taking of photographs to monitor treatment effect and results if desired
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
by my skin care professional.
� 1-3 cups
� 4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your homecare regimen; would that be OK with you?
� Yes
� NoINFORMED CONSENTYour practitioner will recommend the appropriate schedule for future facial treatments or physician referral
In the event of any questions or concerns, I will consult my skin care professionalin order to achieve your skin improvement goals.
immediately. I understand the potential risks and complications and I have chosen toproceed with the treatment after careful consideration of both known and unknown risks,complications, and limitations. I will hold the skin care professional and staff harmless fromINFORMED CONSENT RELEASE
any liability that may result from this treatment.

I agree that this constitutes
full disclosure,
andthat it supersedesverbal
I _________________________________,
do fully understandall thequestions
above and any
haveprevious
answeredthemorwrittendisclosures.
I
certifythatI
haveread,
andfullyunderstandtheaboveparagraphs
andall correctly and honestly. I understand that the services offered are not a substitute for medical care. IthatI
have
had
sufficient
opportunity
fordiscussion
tohaveanyquestionsanswered.
understand that the skin care professional will completely inform me of what to expect in the course oftreatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that
individual results aredependentupon
my age, skin condition, and lifestyle. I agree
to actively participate
ClientSignature________________________________________
Date __________________________
in following appointment schedules and home care procedures to the best of my ability, so that I may
Skin Care Professional ___________________________________ Date _________________________

Circadia
byby
Dr.Dr.
Pugliese,
Inc.Inc.
Circadia
Pugliese,

92

Copyright
2013 2018
Copyright