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 SWiCH
Phlebitis
� Yes
� NoDERMAL REJUVENATION SYSTEM
Serious Injury
� Yes
� No
What __________________________
Initialproblems
on lineSleep
� Yes
� NoThyroid
� High� Low
� NormalVaricose Veins
� Yes
� No
Do you smoke?
� Yes
� No
Do you wear contact lenses?
� Yes
� No

1. I, ________________________________________, understand that the SWiCH™ Dermal

23. Have you ever had a reactionto� Cosmetics
� Metals� Medication
� FoodRejuvenation
treatment
is intended
to improvethe condition andappearance of my� Fragrance

I understandhasExplain_____________________________
been thoroughly studied, clinical trials have been
�skin.
Airborneparticles?that the product� Other
performed on a variety of skin types, and that clinical results may vary according to my

24. FOR WOMEN: Oral contraceptives?
� Noown skin type and conditions. � Yes
Are you pregnant or trying to get pregnant?
� Yes
� No
Are you taking hormone replacement?
� Yes
� No
Do you experience hormone imbalances?
� Yes
� No
2. I agree to complete a Confidential Skin Health Questionnaire. I agree to complete and� Electric shaver?
� Razor?
25. FOR MEN: Do you shave withbe truthful about my physical conditions, pregnancy, medications that I may be taking,Do you experience skin breakouts?
� Yes
� No
and my current skin care regimen.
I am also aware thatmy lifestyle, which if it includes
Do you have ingrown hair?
� Yes
� No
LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

smoking, outdoor exposure, tanning beds, excessive alcohol consumption and/or
recreational use of controlled substances, will effect and diminish the effectiveness andresult of the SWiCH Dermal Rejuvenation treatment.

Is your stress level
� High� Medium
� Low
Do you normally sleepwell?
�Yes
�
No
3. I am aware that I may experience possible short-term effects of reddening, mild stinging
Do you regularly exercise?
� Yes� Nosensations, scabbing, feeling of tightness, and acne-like eruptions in the days following
Do you have food intolerances?
� Yes
� NoWhat?____________________________
the treatment.
Do you follow any special diet?
� Yes
� No
How many glasses of water do you consume daily? ______How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
4. moreI understand there is a possibility of rare side effects, as there is with any product, which� 1-3 cups
� 4 or
has beensafe andeffective in clinical
trials.
ShouldI experiencean extreme
In our treatment program,it mayprovenbe necessary
to recommend
alterations
to oradditions
in your home
response
thisyou?
treatment, I havebeen provided
care regimen; would thatbe OKtowith� Yes
� Nothe contact information for immediate

response for the remedy.

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referralin order to achieve your skin improvement goals.

5. If I have any questions regarding the procedure, I agree to call my skin care professional
to discuss any concerns.

INFORMED CONSENT RELEASE

6. I understand the cost of the treatment and the fee structure has been explained to me.
I _________________________________, do fully understand all the questions above and have answered them
all correctly and honestly. I understand that the services offered are not a substitute for medical care. I
7. careI understandthatwill
I willbe provided
products
thetoskincare inprofessional
theunderstand that the skinprofessional
completely
informme of bywhat
expectthe course followingoftreatment,andwritten
instructions
fortheuseof
theseproducts
havebeen
explained
totreatment and will recommend adjustments to my regimen if deemed necessary. I also am aware thatme. The
clinicallydemonstratedpositive
results of
the SWiCH
DermalRejuvenationindividual results are dependentupon
my age,skin condition,and lifestyle.
I agreeto actively
participate
compliancewith thetoapplicationtheseproducts.
in following appointment treatment
schedules requireand homecare procedures
the best ofofmy
ability,so that I may

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Circadia by Dr. Pugliese, Inc.

89

Copyright 2015

Copyright 2018

Diarrhea/constipation
� Yes
� NoEczema
� Yes� No Where _________________________
Epilepsy� Yes
� No
Hay Fever� Yes
�NoHeadaches
� Yes
� No
How often _____________________
Heart Disease/Conditions
� Yes
� No
What___________________________
Hepatitis� Yes
� NoHIV/AIDS� Yes
� NoInfections
� Yes
� NoLupus
� Yes
� No
8. I understandthat the following conditions
preclude me from having this treatment at thisMenopausal
� Yes
� No
Metal Implants
� Yesthat none of these�conditions
Notime and verify
apply to me at this time.
Pace Maker
� Yes
� NoPhlebitis
� Yes
� NoSerious Injury
� Yes
� NoWhat __________________________
Initial:Sleep problems
� Yes
� NoThyroid� toHigh
� Low� Normal______ Allergic
aspirin or any salicylic
sensitivity
Varicose Veins� toYes
No______ Allergic
citric fruits (oranges,�grapefruit,lemons)
Do you smoke? ______ History�ofYes
� No
being “highly allergic”
to anything
Do you wear contactlenses?
�Yes�
No______ Pregnant or lactating
Currentlytouse ofor systemic)
23. Have you ever______
had a reaction
� antibiotics
Cosmetics (topical� Metals
� Medication
� Food______ Use of Accutane® within the past 12-months
� Fragrance
Airborne
particles?
Other______�Laser
resurfacing
surgery within�thelast Explain_____________________________
12-weeks______
Using glycolic acid products
24. FOR WOMEN: Oralcontraceptives?
� Yes
� No
Are you pregnant
or tryingget pregnant?
� Yes(Vitamin A) in the last
� No______
Use oftoRetin-A®,
Renova®, retinoids
4-weeks
Are you taking______
hormonereplacement?
� Yes
� NoBroken
Skin on areas to be treated
Do you experiencehormoneimbalances? or inflammatory
� Yes lesions
� No______
Visible inflammation
shavewith peels within eight weeks� Electric shaver?
� Razor?
25. FOR MEN: Do you______
RecentDo you experienceskinbreakouts?
� Yes� No______
Herpesvirus (cold sores)on mouth
Do you have ingrownhair?Hair Removal within 6 weeks
� Yes� No______ Laser______ Currently undergoing chemotherapy or radiation treatments
LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

Is your stress level
� High� Medium� Low
Do you normally
sleepwell?
�Yes
�
No
INFORMED CONSENT
Do you regularly exercise?
� Yes
� No
Do you have food intolerances?
� Yes
� NoWhat?____________________________
Do you follow any special diet?
� Yes
� NoIn theconcerns,
How many glasses
ofevent
water ofdoany
youquestions
consume ordaily?
______ I will consult my skin care professional
immediately.
I
understandthepotentialcomplications
and daily?
I have chosen toHow many cups of caffeine-type beverage (coffee, tea,riskssoftanddrinks)do you consume
proceedwith the treatment after careful consideration of both known and unknown risks,
� 1-3 cups�
4 or more
complications,andbe
limitations.
hold the skinalterations
care professionaland staff
harmless
In our treatment
program, it may
necessaryI will
to recommend
to or additions
in yourhome fromcare regimen; any
wouldthat beOK
withresult
you?from this treatment.
� Yes
� No
liability
that
may

I agreethat thisthe
constitutes
full schedule
disclosure,that
it supersedes
anyprevious verbal
Your practitioner will
recommend
appropriate
forandfuturefacialtreatmentsor physician
referralor
disclosures.
I certifythat I have read, and fully understand the above paragraphs andin order to achievewritten
your skin
improvement
goals.
that I have had sufficient opportunity for discussion to have any questions answered.
ClientSignature ________________________________________ Date __________________________INFORMED CONSENTRELEASE
Skin Care Professional____________________________________________________________
I _________________________________,
do fully
understand all the questions aboveDateand haveanswered them
all correctly and honestly. I understand that the services 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 oftreatment and will recommend adjustments to my regimen if deemed necessary. I also am 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

Circadia
Dr.Dr.
Pugliese,Inc.
Circadiabyby
Pugliese,Inc.

90

Copyright
2015 2018
Copyright