MICROCURRENT HISTORY AND CONSENT FORM

Name:_________________________________ Street: ________________________________

City, State, Zip:__________________________ Home Phone: __________________________
Date: __________________________________ E-mail: _______________________________
Mobile Number:__________________ Age: ____________ Gender:M ____ F____

Name and Contact in case of Emergency: _____________________________________________

Whom may we thank for referring you? ______________________________________________
How did you hear about Micro-current therapy? _____________________________________________
____________________________________________________________________________________

Please describe your skin care program-be specific with products and frequency of use: _____________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Have you ever had a professional facial?___ No ___Yes If Yes, How Often?_________
Do you have sensitive skin? ___ No ___Yes If Yes, please describe:___________________________
___________________________________________________________________________________
___________________________________________________________________________________

Have you had any of the following procedures, and if so when?

Chemical Peel ___ When________________

Microdermabrasion ___ When ____________
Skin Resurfacing ___When _______________
Botox/Injectable Filler ___ When __________
IPL ____ When ________________________
Surgery ___ When ______________________

Lifestyle choices can significantly improve or slow the results of this procedure. The following information
will enable us to best customize a sculpting program for you. Please answer as honestly as possible.

YES NO (Age 5 to present) Patient’s comments if Yes

____ ____ Did/do you use tobacco? (List type &amount) ______________________________________
_____ _____Did/do you intake alcohol? (Type and amount per week)______________________________________
____ ____ Salt intake? (Add to food? - seldom/frequently) ________________________________
____ ____ Caffeine intake? (Type and amount per day) _________________________________
____ ____ How many hours of sleep do you get per night? ________________________________
____ ____ How many 8oz glasses of water do you drink per day?________________________________
____ ____ Have you lost or gained any significant weight in the
Last twelve months? If so, how much? ________________________________
____ ____ Are you on a Carb diet? Is so, how long? ________________________________
____ ____ Do you regularly exercise, and if so do you use ________________________________
Weights, Cardio, or both?

What does your diet consists of? (Do you eat healthy foods)? _____________________________________________
_____________________________________________________________________________________________

Certain conditions may restrict or preclude this treatment. Please indicate if you have had any of the following and
if so how long or when was it treated?

YES NO Medical Condition-Please list type

____ ____ Epilepsy?
____ ____ Pacemaker/pacemaker leads?
____ ____ Multiple Sclerosis?
____ ____ Heart Conditions?
____ ____ Metal IUD?
____ ____ Pregnant (Due Date)?
____ ____ Collagen Injections?
____ ____ Botox Injections?
____ ____ Cancer (type and how long?)
____ ____ Skin Disorders or Skin Allergies?
____ ____ Recent scar tissue?
 ____ ____ Facial metal implants?
____ ____ Lack of normal skin sensations?
____ ____ Any circulatory problems?
____ ____ Previous cosmetic surgery or procedures?
____ ____ Do you wear contacts?

If you checked yes to any of the conditions above, please describe: ____________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Please list any prescription medication or nutritional supplements you are currently taking: _________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

What do you want to accomplish with your Micro-current therapy? ___________________________________________

_________________________________________________________________________________________________
_________________________________________________________________________________________________

**Micro-current series purchase expires six (6) months from date of purchase. Paid for but Unused treatments are forfeited
by client if not used within six (6) months from date of purchase.

Expiration Date: Clients signature: .

Client Consent and Authorization

INFORMED CONSENT: I hereby authorize the administration of a skin rejuvenation procedure using the non-surgical Micro-current
therapy machine. I understand Micro-current therapy involves the use of micro currents through the skin. With my signature I am attesting
that I do not currently have any metal inside my body such as pins, screws, plates, pacemaker or defibrillator, etc.

The nature and purpose of the treatment has been explained to me and any questions I have regarding the treatment have been explained to
my satisfaction.

Photographs: I give permission for my photographs to be used to help document my treatment course.
By initialing here I have authorized the use of my before and after photos for marketing and understand I will receive a free gift if they are
used.

No guarantee, warranty or assurance has been made to me as to the results that may be obtained. I am aware that multiple treatments are
necessary for desired results. Most patients require a number of treatments over several months with gradual results occurring over this time.
No refunds will be given for treatments received. I understand and agree that all services rendered to me are charged directly to me and I am
personally responsible for payment.

I release__________________________and his/hers office staff and technicians from liability associated with this procedure. I certify that I
am a competent adult of at least 18 years of age. This consent form is freely voluntarily and shall be binding upon my spouse, relatives, lag
representatives, heirs, administrators, and successors.

My signature below acknowledges that I have had an opportunity to ask and have my questions answered.

Patient’s Signature: Date:____________________________