Perfector Anti-Aging Assessment & Consent Form

Name: Address: City: Province/State: Country: Postal/Zip Code: Home Phone: Cell Phone: Personal email address: Birth Date (dd/mm/yy): Gender:male female Are you currently pregnant/trying to conceive? yes no Work phone: Emergency contact: Emergency telephone: Emergency cell phone: Please indicate if you have ever had any of the following conditions: high / low blood pressure yes fatigue yes heart-related conditions yes diabetes yes insomnia yes depression yes tension yes arthritis yes sinus problems yes bowel / stomach problems yes back / neck problems yes menstrual problems yes epilepsy yes cancer yes HIV yes headaches / migraines yes circulatory problems yes any surgery both past & recently yes Please list any allergies: Please list all medications you are currently taking: Please list any other condition that I should be aware of: What is your skin type? oily dry combination sensitive Do you have any of the following skin conditions? Check all that apply. acne yes psoriasis yes dermatitis yes rosacea yes broken capillaries yes scarring yes Other conditions not listed above? What skin-care products & brand names do you use? What cosmetic products & brands do you use? Were you referred by someone?yes no If yes, please give us their name & phone # so we may thank them: Perfector Anti-Aging Consent Waiver: Jeni Shaw does not make any claims of replacing any medical healing. Treatment is of a complimentary nature only and is taken at the recipient’s own risk. All medical conditions have been disclosed and all contra indications have been clearly discussed. By including my name and checking "yes" to the "I consent" option below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask questions with regard to the described therapy. Name: Date (dd/mm/yy): I consent:yes no

 

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