Form | MADA Clinic and Spa

AlumierMD treatment

Please take the time to fill out the information below prior to treatment:

First name

Last name

Phone

Birthday

Address

I hereby consent to providing the above data for use in respect of my treatment. In the unlikely event that I experience any adverse reaction, I further consent for this information to be shared with AlumierMD, for further investigation and advice.

WHAT’S THE MAIN REASON FOR YOUR AESTHETIC CONSULTATION?

WHICH OF THESE STATEMENTS ARE MOST APPLICABLE TO YOU?

I would like to look better for my age.

I would like to change something that has been bothering me for a long time

I would like to look more attractive.

HAVE YOU HAD AN AESTHETIC CONSULTATION OR TREATMENT BEFORE?

yes

HOW OFTEN DO YOU THINK ABOUT HAVING AN AESTHETIC TREATMENT?

Most days

Weekly

Monthly

Whats is the area of your concern?

What are your concerns and when did you first notice them?

Do you notice it's worse at any times of the day/month/year?

What skin care products are you currently using?

HOW DID YOU HEAR ABOUT US?

Have you taken Roaccutane in the last six months?

yes

Are you allergic to Aspirin (acetylsalicylic acid)?

yes

Have you had a cold sore the last 7 days and/or have you ever had a cold sore?

yes

If 'yes', how frequently/easily do you get them? When was your last cold sore?

Are you currently under the care of a medical professional (dermatologist/oncologist/obstetrician/ endocrinologist)?

yes

If 'yes' please provide more details.

Have you ever been treated for skin cancer? If 'yes' please provide more details.

Are you currently taking any prescription medicines (antibiotics/antidepressants/ blood thinners)? If 'yes' please provide more details.

Are you currently using any topical prescription medicines (retinoic acid/ topical antibiotic/topical steroids)? If 'yes' please provide more details.

Do you have any illnesses or health conditions? If 'yes' please provide more details.

Have you ever been diagnosed with a skin condition? If 'yes' please provide more details.

Do you have any undiagnosed skin lesions? If 'yes' please provide more details.

Do you have any allergies? If 'yes' please provide more details.

Have you had laser/IPL/radio frequency/ chemical peel in the last 2 weeks? If 'yes' please provide more details.

Have you had filler injections in the last two weeks? If 'yes' please provide more details.

Have you had neurotoxin/filler/ microdermabrasion/enzymatic peeling/waxing/ threading etc. in the last 7 days? If 'yes' please provide more details.

Have you shaved the area to be treated in the last 24hrs?

Have you ever used any skincare products that caused an adverse reaction? If 'yes' please provide more details.

Do you smoke? If 'yes' how many cigarettes/ cigars a day?

Do you drink alcohol? If 'yes' how many units a week?

Are you using AHAs/BHAs/non-prescription retinol in your current skincare routine? If 'yes' please provide more details.

Have you used retinol (prescription or nonprescription) in the last 7 days? If 'yes' how many days ago?

Do you wear contact lenses?

Do you have semi-permanent make-up?

Is there anything else at all that your practitioner may wish know or consider during your consultation or treatment?

FULL DISCLOSURE: Prior to receiving treatment, I have completed and signed the Patient Profile given to me by my physician/ skincare professional. I have been truthful in disclosing information that may have bearing on this procedure.

I agree to use the recommended sun protection product (SPF 30 or higher) on the treated area for a minimum of 14 days post treatment. I understand AlumierMD recommends using a sunscreen of SPF 40 or higher.

I agree to refrain from the following activities for 7 days post treatment and accept full responsibility for any adverse event that occurs as a result of my participation in these activities:• Waxing, threading, and use of all other depilatories• Neurotoxin injections (e.g., Botox, Dysport)• Use of retinoids• Use of mechanical exfoliants• Use of topical AHA/BHA and all other exfoliant topical skincare products• Use of sunless tanning products• Acne topical treatments I agree to refrain from the following activities for 14 days post treatment and accept full responsibility for any adverse event that occurs as a result of my participation in these activities:• Sun or tanning bed exposure• Microdermabrasion• Laser hair removal• Dermal filler injections I understand and accept that the following may occur post treatment:• Likely: Temporary sensation of heat and itchiness immediately following treatment• Possible: Contact dermatitis, inflammation(redness), oedema (swelling), skin irritation (itchiness)• Unlikely: Hyperpigmentation/hypopigmentation: I agree to follow the recommended post-procedure instructions to minimise the chance of this occurring.

AFTER YOUR TREATMENT

You have just received an AlumierMD Skin Treatment. Results from your chemical peel treatment can be affected by a number of factors. To maximise on the potential of your treatment and reduce the risk of complications, please follow the post-peel instructions outlined in this form.

AlumierMD skin treatments result in minimal downtime but create dramatic and visible results. However, treatments may cause the following for two to 24 hours (these are normal, expected outcomes and are not reason for concern): Redness / Tightness / Itchiness / Sensitivity /Slight swelling

Specific treatments may cause the following for three to five days. These are normal, expected outcomes and are not reason for concern: Temporary dryness / Skin peeling / flaking

The treated area may or may not actually peel as each treatment is individual.

It may take two or more treatments to target the deeper layers of skin to loosen and 'peel'.

The degree of peeling does not necessarily reflect the efficacy of the procedure.

Refrain from removing peeling skin by any means including picking, peeling and exfoliating as it could result in hyperpigmentation or scarring.

CARING FOR YOUR SKIN AFTER TREATMENT

Following specific treatment, you will be asked to avoid getting the skin wet for eight hours.

Following treatment, you will be asked to avoid makeup, self tan products, direct sun exposure, ice or ice water on the treated area and excessive heat for the rest of the day.

Following treatment, you will be asked to avoid hot tubs, steam rooms, saunas, excessively hot showers, swimming and aerobic exercise for two days.

Following treatment, you will be asked to avoid AHA and BHA skincare for three to five days.

Following treatment, you will be asked to avoid electrolysis, waxing, threading or any other form of hair removal for seven days.

Following treatment, you will be asked to avoid tanning booths, facial scrubs or mechanical forms of exfoliation, retinoic acid, laser hair removal, photofacials, chemical peels or microdermabrasion for 14 days.

You will be offered a Post Peel Kit, which contains SensiCalm cleanser, Hydrating Recovery Balm and Sheer Hydration Broad-Spectrum Sunscreen SPF 40 Untinted. If you have any questions regarding your treatment, don’t hesitate to contact your AlumierMD professional who will be happy to speak with you further.

In case of emergency such as allergic reaction, please contact your physician and proceed to the nearest emergency room.

YOUR POST-PEEL KIT

This post-treatment kit has been created to care for your skin following a chemical peel or professional treatment. Follow the post-peel regimen and use only the three AlumierMD products in this kit for five to seven days:

1. SENSICALM CLEANSER (15 mL / 0.5 Fl. oz)

A smooth hydrating cleanser, that delicately removes impurities and excess oil while calming skin. Yucca root extract is a gentle natural cleanser; niacinamide, ceramides, vitamin E and sunflower seed oil moisturise, leaving skin smooth, soft and intensely hydrated. Aloe soothes skin and calms redness. Instructions: Massage into skin and rinse thoroughly.

2. RECOVERY BALM (15 mL / 0.5 Fl. oz)

Specifically formulated for post-procedure recovery and packed with soothing and antioxidant ingredients, this moisturiser relieves redness and calms skin. Hinokitiol and sea whip relieve redness, aloe, honey and boswellia soothe and copper peptide rehabilitates the look of skin. Instructions: Gently massage into clean skin withfingertips. Apply during the day as needed.

3. SHEER HYDRATION BROAD SPECTRUM SPF 40 SUNSCREEN (15 mL / 0.5 Fl. oz)

A silky and sheer physical sunscreen that provides powerful protection against harmful UVA and UVB rays. It uses a combination of zinc oxide and titanium dioxide, while moisturising with vitamin E. This formula is also packed with free-radical quenching antioxidants, including resveratrol, grapeseed extract and glutathione, to protect skin from UV damage. Instructions: Apply liberally to treated areas after cleansing and applying Recovery Balm. Reapply throughout the day.

A.M. PROTOCOL

STEP 1: SensiCalm Cleanser

STEP 2: Recovery Balm

STEP 3: Sheer Hydration Broad Spectrum Sunscreen SPF 40

P.M. PROTOCOL

STEP 1: SensiCalm Cleanser

STEP 2: Recovery Balm

Discontinue use if any products cause burning on the skin and contact your skincare provider.

If you have any questions or concerns, please contact your AlumierMD professional.

I agree to follow all post peel instructions outlined in this document and accept full responsibility for any adverse event that occurs as a result of me failing to do so.

I hereby authorize MADA Clinic and Spa to use my photo and/or information related to my experiences with my treatment with associated devices and products. I understand this information may be used in publications, presentations, promotional literature, advertising, social media and/or other similar ways.

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