CLIENT CONSULTATION AND RELEASE FORM Please read carefully, complete, sign and date this form prior to your treatment. Name: __________________________________ Phone: (______) __________________ Address: ________________________________________________________________ City: _________________________________ State: ______ Zip: __________________ �HYDRAFACIAL �MICRODERMABRASION �BLUE LED LIGHT THERAPY �ULTRAMAX �RED LED LIGHT THERAPY �LYMPHATIC/MASSAGE THERAPY SECTION 1: MEDICAL INFORMATION • Do any of the following conditions relate to you? YES NO ��Accutane or other similar medication ��Allergies ��Autoimmune disease, HIV, lupus, hepatitis ��Blood thinners – Heparin, Coumadin, Warfarin, etc. ��Breast feeding, pregnancy ��Cancer or post-cancer treatments ��Cardiovascular problems ��Cold sores or fever blisters without pre-medication ��Cortisone or steroid injections ��Cosmetic injections, fillers or implants, (i.e. Botox®, collagen) ��Eczema, psoriasis ��Enlarged or painful glands ��Epilepsy ��Facial waxing services w/in 7-14 days ��Heart ailment ��Hypertension/high blood pressure ��Inflammatory conditions ��Irregular, pigmented moles, warts or growths, unidentified facial growth or mark ��Keloids, pigmented scars, icepick scars, new scar tissue ��Laser procedures, chemical peels, dermabrasion, microdermabrasion ��Light sensitive medication ��Loose, thin, aged skin ��Lymphatic disorder, inflammation of lymph vessels, lymphedema ��Medication: ��Pacemaker or metal implants ��Phlebitis, varicose veins ��Recent accident or serious injury ��Recent surgical or dental procedure ��Rosacea, telangiectasia/couperose ��Retin-A, Retinol ��Skin abrasions or lesions ��Stage III or IV acne ��Skin-lightening or bleaching agent ��Sunburn ��Swollen or infected tonsils ��Thyroid conditions (Continued on next page) Rev 8/28/08 Courtesy of Edge Systems Corporation �2007 Edge Systems Corporation �www.edgesystem.net
��Type I diabetic ��Under medical care for an existing or suspected condition or disease ��Viral infection, influenza ��Other contraindication at discretion of skincare technician or medical practitioner: • My interest in skincare treatment is primarily for (i.e. skin rejuvenation, acne, hyper-pigmentation, scarring, etc.) ______________________________________________________________________________ ___________________________________________________________________________________ • Specify your areas of concern (i.e. eyes, forehead, etc.) _______________________________________ ____________________________________________________________________________________ SECTION 2: CLIENT CONSENT FORM (Initial each acknowledgement line below) 1. I acknowledge that I have not used Accutane or any medication for the same purpose during the last 12 months. _____(initial here) 2. I acknowledge that if I have ever had a cold sore or fever blisters, I should consult with my physician or pharmacist for a pre-use medication to help avoid a possible breakout. That medication should be used each day for two days before, same day, and two days after any aggressive facial exfoliation treatment. _____(initial here) 3. I acknowledge that there is no guarantee that dark discoloration of skin will be reduced or fade. Pigmentation may improve or darken with successive treatments. I acknowledge the need for proper skin care home regimen. _____(initial here) 4. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. _____(initial here) 5. I acknowledge that if I fail to use a minimal sunscreen (SPF 15), I am more susceptible to sunburn, skin damage& hyperpigmentation. _____(initial here) 6. I acknowledge that this treatment is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied. _____(initial here) 7. I acknowledge that I should avoid use of glycolic products for 2-4 weeks following the treatment. _____(initial here) 8. I acknowledge that I should avoid use of Retin-A type products for a period of time recommended by my �medicalor �skincare professional during and following the treatment. _____(initial here) 9. I acknowledge that I am not pregnant/lactating. _____(initial here) 10. I hereby agree to have the treatment performed and agree to follow all pre and post treatment instructions. _____(initial here) 11. I acknowledge that I have answered all questions truthfully and completely. _____(initial here) 12. I release the instructors, management and staff of Edge Systems Corporation and __________________________, from any and all liability associated with any injuries and/or current or future conditions resulting from the skincare procedures or products. _____(initial here) 13. I consent to the use of my before, during and after facial procedure photographs for education, promotion or advertising purposes. _____(initial here) Client Signature: ____________________________________________ Date: ___________________________ Skincare Practitioner Signature: _________________________________ Date: _________________________
o que caTam as mãos do caTa-dor? uma experiência com caTadores da ascaVap em parceria com o insTiTuTo de arTe conTemporânea inhoTim Mariana Guimarães [email protected] Este artigo tem como objetivo apresentar e narrar a oficina de arte-educação realizada com trabalhado-res da Associação de Catadores do Vale do Paraopeba – ASCAVAP – Brumadinho, MG.1 O trabalho foi rea
Volume 35, N° 5, 2008 Contrefaçon de médicaments : la vigilance s’impose (Héparine, Viagra et dérivés, tous frelatés ?) trait d’un lot en cas de nécessité. de l’échec thérapeutique à l’appa-s’est fait récemment jour. Il s’agit Contrefaçons de médicaments PHARMA-FLASH Volume 35, N° 5, 2008 net ont été identifiés. Zhong Hua Niu Bian , une spécialit