Alpenglow Consultation Form

Relaxation
Results
Corrective Facials
Chemical Peels
Derma-planing
Home-care Products
Treatment Plan
Virtual Consultation
In-Person Consultation
Skin Prep
Retin-A
Tretinoin
Differen
EpiDuo
Tazorac
Accutane
Clindamycin
Spironolactone
None
Other
No
Yes
No
Yes
Aspirin
Nuts
Gluten/Wheat
Ragweed
Botanical Essential Oils
Other
Eczema
Psoriasis
Dermatitis
History of Skin Cancer
Other
Normal
Dry
Oily
History of Skin Sensitive
Combo
No
Yes
No
Yes
***New data proves screen lighting and indoor LED lighting damages skin
Hyperpigmentation/Melasma/Sun Damage
Sensitivity/Rosacea/Redness/Flushing
Aging/Fine Lines/Wrinkles/Collagen Loss
Blackheads/Pimples/Breakouts
Cystic Acne/Scarring
Uneven Skin Tone/Uneven texture/Large Pores
Impaired Barrier Function/Dryness/Dehydration
Other
No
Yes
***Some of these products will be changed seasonally or as your skin changes into a maintenance plan
Please check here to acknowledge that you are aware of the "No Sweating Rule" for the first 48 hours after a chemical peel treatment to avoid complications.
Bare Minimum 1-3
A Good Start 2-4
A Complete System 4-6
Whatever it takes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
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I understand skin care services and recommendations are not a substitute for medical examination, diagnosis, or treatment. I have been advised that services provided by this spa could have unfavorable results including but not limited to allergic reaction, irritation, burning, lifting, redness, tingling, peeling, soreness, etc. I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services. I hereby confirm that I am not using any medication or product that may cause or contribute to any such injury/reaction and I will advise my esthetician during each visit if I should change medications/product that may affect my waxing or facial treatment. I will not hold Courtney Parkhill at Alpenglow Skin Spa responsible should there be any unfavorable results for this appointment or any future appointments. I understand that if I’m receiving a chemical peel, facial or derma-planing that for 48 hours after treatment, I will keep my skin cool and avoid extreme heat/cold that may otherwise cause hyperpigmentation or water blisters or an unfavorable peeling process. I will also follow post-procedure guidelines outlined by my esthetician to follow for 7 days after my treatment. I will not pick loose skin that could cause scarring, I will stay moisturized and wear a daily spf of 45 or higher and reapply throughout the day to protect my skin whether I’m inside (HEV lighting and screens) or outside (UVA/ UVB lighting). I understand that I do not need to peel to achieve the result. I also understand that direct sun exposure is prohibited while undergoing any treatment at Alpenglow because freshly exfoliated skin is more susceptible to sun damage. I also understand that to achieve results I may need several treatments. I agree to refrain from tanning beds, and understand there may be no guarantee as to the results of this treatment, due to many variables such as: age, diet, hormones, condition of skin, sun damage, smoking, climate, compliance, commitment, proper home-care product usage, etc. I understand the treatment is cosmetic and that no medical claims are expressed or implied. Lastly, I understand that I should follow my esthetician’s recommendations for prep/post-procedure to minimize side effects and maximize results.