Client Name: *

Date of Birth *

Procedure Date: *

Introduction to the Treatment

Dermalogica facial treatments are tailored to meet the specific needs of your skin using high-quality, professional-grade Dermalogica products. These treatments include a combination of cleansing, exfoliation, extractions (if necessary), masks, and moisturization designed to target various skin concerns such as acne, fine lines, pigmentation, dehydration, and more. The products and techniques used will be customized based on a thorough skin analysis.

Pre-Treatment Questions

Have you had a Dermalogica facial or any professional skincare treatments before?

Yes

Do you have any known allergies, particularly to skincare products or ingredients such as fragrances, preservatives, or essential oils?

Yes

If yes, please specify:

Do you have any current skin conditions or concerns such as acne, rosacea, eczema, psoriasis, or dermatitis?

Yes

If yes, please specify:

Are you currently using any prescription medications, topical treatments, or over-the-counter products that could affect your skin?

Yes

If yes, please list:

Are you currently using any of the following? (Please check all that apply):

Retinoids (e.g., Retin-A, Tretinoin)

Exfoliating acids (e.g., AHAs, BHAs)

Accutane or other oral acne medications

Blood thinners (e.g., aspirin, ibuprofen)

Other:

Do you have a history of cold sores or herpes simplex virus (HSV) outbreaks, especially around the mouth or face?

Yes

Are you pregnant or breastfeeding?

Yes

Treatment Procedure and Expectations

What are your primary concerns or goals for this facial treatment? (Check all that apply)

Other

What are your expectations from the facial treatment?

Do you understand that some treatments may involve exfoliation, extractions, or use of potent ingredients that can cause temporary redness, swelling, or mild irritation?

Yes

Are you willing to follow any post-treatment care instructions provided by your practitioner to ensure optimal results and skin health?

Yes

Potential Risks & Side Effects

While Dermalogica facials are generally safe, there are potential side effects, including but not limited to: *

Temporary redness, irritation, or sensitivity post-treatment

Breakouts or purging (temporary increase in acne as impurities are brought to the surface)

Dryness, flaking, or peeling

Allergic reactions to specific products (though rare)

Minor discomfort or tightness following the procedure

Post-Treatment Instructions

To maximize the benefits of your facial, you should: *

Avoid sun exposure and use SPF 30+ sunscreen daily.

Refrain from using harsh exfoliants or any products with active ingredients for at least 48 hours post-treatment.

Hydrate your skin with recommended products.

Avoid touching or rubbing your face to reduce the risk of irritation.

Consent & Acknowledgment

By signing below, I acknowledge that: *

I have provided accurate information to the best of my knowledge regarding my medical history, skin condition, allergies, and current medications.

I understand the nature of the Dermalogica facial treatment and any potential side effects or risks associated with the procedure.

I have had the opportunity to ask any questions about the treatment, and all my concerns have been addressed.

I understand that the results of the treatment may vary depending on my skin type and condition.

I consent to receiving the Dermalogica facial treatment and agree to follow all pre- and post-treatment instructions.

Date: *

Client Signature: *

Clear

Practitioner Name: *

Practitioner Signature *

Clear

I agree to terms & conditions provided by the company.

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