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Catering menu and prices for spa party 10/02/04

Patient Consent for Facial ProcedureVisage

Client Name:

Consent must be granted to perform the following facial procedures. The below described advanced
professional skin care treatments can be aggressive chemical or mechanical resurfacing, or use electro-
current tools. They may not penetrate the skin or perform any services that would affect living tissue.

This treatment combines organic skin care products and bio-electronics. With the use of micro-current
technology, we are able to effectively and non-evasively care for the skin in the deeper layers of the epidermis.
Outlines of the face are strengthened and naturally lifted with the ‘toning' phase of the treatment. Tissue repair
and waste is eliminated from the face in the ‘detox' phase of the treatment, which is included in our acne facial.
Outlines of the face are strengthened and naturally lifted. Soft tissue restructure and skin repair will be the
results. The results will be lasting because the cells are repaired and tissue has been re-built. We recommended
series of 10 for long-lasting results.
Contraindications:
If you have any of the following conditions, you are not a candidate for this procedure. Please circle any of
the following conditions that you have currently.
Skin Cancer
Heart problems
Epilepsy
Seizure
Thrombosis
Phlebitis
Infectious disease
HIV
Hepatitis
Cardiac Pacemaker
Metal Implants
Anabolic Steroid
I have read and understand the above descriptions and conditions of the procedure(s) I have marked. I am
responsible to inform the Skin Care Therapist if any of the contra-indications for the procedure exists.
_
signature
1528 Plumas Court, Ste 300
Yuba City, California 95991
Patient Consent Form for Facial Procedure: Glycolic Peel

Client Name:

Consent must be granted to perform the following facial procedures. The below described advanced
professional skin care treatments can be aggressive chemical or mechanical resurfacing, or use electro-current
tools. These surface peels are used to treat many skin problems such as acne, pigment changes, and sun-
damaged skin. A glycolic peel is using glycolic acid on the skin at certain times. The acid removes the surface
skin cells so that the deeper cells can rebuild. This process results in a better look and quality of the
skin. Glycolic peels are known for the way they soften skin, improve sun damage, reduce fine lines, reduce mild
scars, and improve pigment flaws. They cannot improve lax skin or deep scars, remove broken blood vessels, or
remove pigment problems in those with dark skin. With any type of peel, there is a risk for problems such as
excess color or discoloring and scarring. However, unlike deeper peels, glycolic peels have a low risk for
problems. They may not penetrate the skin or perform any services that would affect living tissue.
The glycolic acid peel that is used at Spa Therapy is a 30% glycolic acid concentration with a 2.3 pH. It is an
aggressive exfoliation treatment. It will smooth the skin, visibly reducing acne scarring and/or fine lines.

Before the Treatment
For one week before the treatment, you should avoid things that could bother your skin such as electrolysis,
waxing, hair removal creams, masks, hair dyes, perms for hair, hair straightening treatments, and Retin A. If
you use face cream, which has a mild alpha-hydroxy acid (AHA), you should keep using it before the acid
treatment. If you have had cold sores or shingles, you need to tell your doctor. In these cases, you may need to
take medicine before the peel.
Procedure
The strength of the peeling agent and length of time depends on your skin type. It takes only a few minutes to
apply. During the process you may notice an odor as well as a stinging or tingling feeling on your skin. You
will be told to rinse your face with cool water right after the agent is applied.
After the Procedure
Your skin may look slightly pink for a few days. During this time, your skin may be more likely to sunburn.
You may also notice a small amount of skin flaking like what you have after mild sunburn. This is normal and
will go away in a few days. Some patients may not have much flaking but still have good effects from the peel.
Care after the Procedure
1. Avoid sun for the next week. If you are unable to avoid the sun wear a sunscreen with an SPF of at least 30
and a wide-brimmed hat.
2. Apply a moisture lotion 2 times a day until the skin appears normal, about 3-7 days, unless advised to do
otherwise.
3. Wash the treated area very gently with mild soap and water. To avoid the chance of scarring, avoid picking,
peeling, and scraping your skin.
1528 Plumas Court, Ste 300
Yuba City, California 95991
4. Avoid using any irritants such as Retin A®, alpha-hydroxy acids, masks, or astringents for 1 week or until redness or sensitivity has gone away. 5. You may begin wearing make-up later in the day, if your skin is not sensitive. Otherwise, wait for the sensitivity to go away. 6. If the chin area has been treated, men should not shave for 2 days or until any redness has gone away. Problems 1. Normal side effects may include mild irritation, sensitivity, redness, or minor skin breakout right after and up to a few weeks after the peel. 2. More serious side effects for which you should notify our clinic are:  severe redness  cold sores or blisters
If you have any of the following conditions, you are not a candidate for this procedure. Please circle any of
the following conditions that you have currently.

Skin Sensitivity Autoimmune Disease Black or Dark Olive Skin Cuts or bruises on area to be treated Eczema Herpes Pregnancy or Nursing Seborrhea Tobacco use Allergies Skin thinning drugs or application (Retin-A, Accutane, etc) Sunburn Exposure to UV light (Indoor Tanning) I have read and understand the above descriptions and conditions of the procedure(s) I have marked. I am responsible to inform the Skin Care Therapist if any of the contra-indications for the procedure exists. _ signature/ date 1528 Plumas Court, Ste 300
Yuba City, California 95991

Patient Consent for Facial ProcedureTreatment

Client Name:
Our Microdermabrasion equipment is crystal free and utilizes a diamond-tip dermabrasion wand. This is an
aggressive mechanical skin resurfacing treatment. It will smooth and resurface the outer layers of the
epidermis, visibly reducing acne scars, fine lines, age-related imperfections, hyperpigmentation, and sun
damage, to name a few.
If you have any of the following conditions, you are not a candidate for this procedure. Please circle any of
the following conditions that you have currently.

Skin Sensitivity Autoimmune Disease Cuts or bruises on area to be treated Eczema Herpes Pregnancy or Nursing Seborrhea Tobacco use Allergies Skin thinning drugs or application (Retin-A, Accutane, etc) Sunburn Exposure to UV light (Indoor Tanning) I have read and understand the above descriptions and conditions of the procedure(s) I have marked. I am responsible to inform the Skin Care Therapist if any of the contra-indications for the procedure exists. _ signature/ date 1528 Plumas Court, Ste 300
Yuba City, California 95991

Source: http://www.yubacityspa.net/files/facialconsent.pdf

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