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Name: Date: DOB: Phone: Email: Service: Notes: `

TODAY S DATE REFERAL NAME/LAST FIRST M F DOB (OPTIONAL) ADDRESS CITY STATE ZIP PHONES/HOME WORK CELL EMAIL ADDRESS FAX NUMBER HEIGHT FT IN WEIGHT OCCUPATION Are you currently taking any medications? Do you have allergies to any medications? Do you have any allergies? Have you ever suffered a severe allergic reaction, explain? Have you ever had an allergic reaction to local anesthesia, explain? Do you smoke? How many years? How much /day? Have you ever smoked? How many years? How much /day? Have you ever had surgery? List Have you ever had cosmetic surgery? List Do you have cardiovascular or heart disease? Do you have diabetes? Do you have epilepsy? Is there any incidence of cancer in your family? Do you have hepatitis? Do you have migraine headaches? Do you have asthma/hay fever? Do you have high/low blood pressure? Have you ever had herpes, cold sores, fever blisters, keloids, hives? Are you currently under a physician s care? Explain Do you have venereal disease, HIV, AIDS? Do you have thyroid or kidney problems? Do you have emphysema? DO you have incidents of fainting or dizzy spells? Do you have any drug addictions? Do you have anemia? Do you have arthritis? QUESTIONS RELATING TO SKIN/SKIN CARE Is your family prone to vascular blemishes? Spider Veins Varicose leg veins cherry anginoma broken facial capillaries Upper body capillaries? Have you ever visited a dermatologist, plastic surgeon, cosmetic dentist, or other skin care therapist?_list

Have you ever used Retin A or a similar product? Do you use skin products such as moisturizer, cleanser? Explain Do you suntan? Do you use sunscreen? Do you follow a diet and watch your caloric intake? Do you follow an exercise routine? Is your skin: Dry Oily Normal Combination Are you Fair Olive Asian Hispanic Native American African American What are you concerns with your skin? How much liquid do you drink /day? What vitamins/minerals do you take regularly? Comments I have completed the Health History questionnaire. I am in good physical condition and mental state. I have no physical restrictions, conditions, disabilities or ailments that are not noted here. I am cleared by my health care professional to get treatment from the Z Medi Spa. Signature Printed Name NOTES:

GENERAL INFORMED CONSENT I, consent to, and authorize the staff of ZMediSpa to perform: laser (Hair Removal/IPL/Skin tightening/resurfacing/tattoo removal), skin (Peels/facials/ect.), injectables (Filler/Toxins/PRP) and Body Contorting (Vanquish). 1. The nature and purpose of the treatment(s), its possible benefits, and alternative treatments have been explained to me. Any questions I have regarding this treatment have been answered and explained to my satisfaction. (Initial) 2. I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these potential risks. (Initial) 3. Possible side effects include, but are not limited to, mild redness, extreme redness, bruising, local swelling, stinging, tenderness, dry skin, flaking, lightening or darkening of the skin, infections, pimples, post inflammatory hyper pigmentation, bumpy appearance, cold sores, or scarring. Most side effects are temporary and generally subside within 72 hours. (Initial) 4. If I am prone to Herpetic outbreaks (cold sores or fever blisters), I understand that I may need to take any oral anti-viral medicine. If necessary, the ZMediSpa staff will supply me with the appropriate prescription for this medicine. (Initial) 5. I acknowledge that no guarantee or assurance, expressed or implied, has been made by anyone regarding this treatment, or series of treatments, which I have herein requested and authorized. (Initial) 6. I realize that the procedure may not be successful and the result may not be as I fully desire. (Initial) 7. I give my consent to the administration of anesthetics. (Initial) 8. I agree to adhere to all safety precautions and home post-treatment skin care programs recommended by the ZMediSpa staff. (Initial) 9. I am over 18 years of age or I have parental consent (co-signed below) (Initial) 10. I will inform the ZMediSpa staff of any complications I may develop, as soon as they may occur. (Initial) 11. I am aware of the 24 hour cancelation policy and know that there is a $25 fee for all no shows and late cancelations. (Initial) 12. I am aware that ZMediSpa may need to take my photo. I authorize them to be used for in office use like charting (Initial) & marketing materials (Initial). Name Date Client Signature Parent or Guardian Signature (if client is a minor) Witness

CREDIT CARD ON FILE POLICY At Z Medi Spa we require keeping your credit or debit card on file for cancellation/ no-show fees of $25 for appointments missed or canceled within a 24 hour period. Your credit card information is kept confidential and secure and payments to your card are processed only after the claim has been filed and processed by your insurer. I authorize Z Medi Spa to charge the following credit or debit card: Credit Card Number Type: Expiration Date / / Cardholder Name Signature Billing Zip I (we), the undersigned, authorize and request Z Medi Spa to charge my credit card, indicated above, for balances due for services/cancellations rendered that is my financial responsibility. This authorization will remain in effect until I (we) cancel this authorization. Patient Name (Print): Signature Date / /

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