INJECTION HISTORY SHEET Brick CMCH EHT Festival Galloway Somers Point Wall Twp. Name________________________________________ Date___________________ Age_________ LMP________Weight ________ Exam______________Referring Physician____________________ Why are you having today’s exam?______________________________________________________ ____________________________
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Luminosity skincareLuminosity Acne Skincare
Name:_______________________________________________ Birth Date:________ Age:_______ Phone #: ________________
Address:______________________________________________ City:_____________________ Zip Code:____________________
Email Address:____________________________ How did you hear about us? __________________________________________
When did you start to get acne? _____________________ Which areas are affected by acne? Face, Chest, Back, Upper Arms
Check if you are allergic to: __sulfur __aspirin / salicylic acid __ latex __almonds/nuts __benzoyl peroxide
Other Allergies: _____________________________________________________________________________________________
Are you pregnant, trying to get pregnant or nursing? ______ Are you on birth control pills? ______
Do you use Norplant, Mirena, Provera, Depo-Provera shots or Nuvo Ring? ______________
Are you prone to Cold Sores or have Herpes Simplex 1? ______ Acne treatments & products may stimulate an outbreak in prone
individuals. Client assumes all risk involved in the case of a stimulated outbreak. We ask that you reschedule any appointments if you
have an outbreak.
Are you prone to keloids? _______ Have you had a bad reaction to chemical peels in the past? ________
List all current dermatologist prescribed acne medications & topicals: ____________________________________________________
Circle the following conditions that apply to you: Eczema, Psoriasis, Hepatitis, Cancer, HIV, Thyroid Problems, Hysterectomy,
Hemophilia, Lupus, Anemic, Cold Sores/Herpes Simplex 1, High Blood Pressure, Diabetes, Polycystic Ovary Syndrome (PCOS)
Do you sun bathe or use a tanning bed? ________ Do you use sunscreen daily?________ Do you smoke? _______
Do you use liquid fabric softeners or dryer sheets? _____________ Do you pick at your skin? _______
Your stress level is: LOW MEDIUM HIGH Do you swim frequently? ________
How many hours of sleep do you get per night on average? ________ Do you work night shifts? ____________
Do you workout, play sports or do any strenuous activity? _______
Do you regularly eat: (Circle all that apply)
kelp/seaweed salt dairy/cheese protein powders soy fast food soda
deli meat (sliced turkey, ham, bacon, etc) canned vegetables peanuts/peanut butter
I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I agree to
assume all risk and responsibility and to hold Luminosity Acne Skincare harmless in the event I sustain any injury or
damage to my person, directly or indirectly, as a result of my receiving services or using their products, and I further agree
to release Luminosity Acne Skincare and its employees from any claim, cause of action, suit, damages, etc. that may
result from any such injury or damage.
By signing this form I understand that:
Most clients will be clear of their acne in 3-4 months, however, due to genetics, stress, lifestyle habits, hormonal issues,
diet, medical conditions, and prescription medications some acne cases may be very difficult to treat. I understand there is
no money back guarantee on products or treatments. I understand that compliance to the recommended homecare
products and treatments will play a key role in the success or failure of this program.
Client Signature:___________________________________________________ Date:___________________________
Parent/Guardian Signature if under 18 years of age:_________________________________ Date: _________________
Cancellation & No Show Policy
Luminosity Acne Skincare is by appointment only. Your appointment is time reserved exclusively for you and we request
that you please review our cancellation policy.
If you made an appointment and need to reschedule or cancel, we require a minimum of 24-hours notice. You may
contact us by e-mail or call us at 919-840-8184. Leave your information on our answering
service if we are unable to answer your call.
Clients who do not honor their appointments will be charged a cancellation fee as follows:
Failure to show without notice or same day 100% of the treatment service price will be charged as following: $25 for Acne Consultation *Above fee is for same day cancellation. Clients who do not show up for consultation without notice will not be rebooked for our services. $80 for Acne Treatment or Pigmentation Fading Treatment Arriving late will limit the time for your treatment. As your service was reserved at a specific time, your treatment will end at its set end time so that the next guest is not inconvenienced. The full treatment price will apply for late arrivals. Client Signature:___________________________________________________ Date:___________________________ Parent/Guardian Signature if under 18 years of age:_________________________________ Date: _________________
For Morse ML: Mind Without Brain: A Scientific Analysis of Near Death Experiences With Special Attention to Those In Children. A New Scientific Paradigm of Consciousness. Annais do 4th CIPRO Congresso International of Consciousness and Conscientiology. International Journal of Consciousness Vol 11 no 41 pp 183-208 August 2008 1. Morse ML, Perry, P. Parting Visions: Uses and Meanings of Pre-Dea