TLC BUTTERFLY EFFECT SPA LLC (DBA) IPL PHOTOFACIAL CUSTOMER CONSENT FORM AND RECEIPT

 
 
Name *
Name
Address *
Address
Phone *
Phone
Please see your facial professional before beginning any facial treatment. There is a $25 fee NOT covered by any coupon presented upon service. This fee is for your required facial consultation in order to complete your procedure today.
• Results vary based on initial skin condition (most clients see 1-3 level improvement. • You will not experience any heat or discomfort from the creams used to clean your face • Rarely clients experience a tingling sensation this will end when the product is rinsed off • This process will not clear your face more than their genetic traits • This product is used with a light source
Do you follow a structured skin care regimen today? *
Would you best describe your skin as oily, dry, or a combination? *
How would you describe your skin's sensitivity? *
Correct Facial Sagging, Eyebrow Drop, improve jaw line definition *
Improve volume in areas (cheeks, lips, etc) *
Correct facial wrinkles/creases *
Improve acne / rosacea *
Get rid of facial veins and/or redness *
Correct Scarring *
Correct Sunspots *
Correct precancerous spots *
Improve general appearance of skin tone / health *
Minimize the appearance of under eye bags? *
Do you have allergies or reactions to cleansing creams, peroxide or glycerin? *
Are you photosensitive to light or currently on any photosensitive medicines? *
Are you pregnant, suspect you’re pregnant or breastfeeding? *
Under the age 18 (requires parent consent) *
Have you had facial surgery or micro-derms, facial peeling in the last 30-days? *
Are you wearing piercing or metal objects in your mouth please remove if possible *
Today's Date *
Today's Date