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Facial Treatment Information

Please provide information on any recent treatments you’ve received.

Botox (How recent?):
Threads (How recent?):
Fillers (How recent?):
Facelift (How recent?):

Have you had any of the following treatments in the last month?
Chemical PeelsLaser treatmentsMicrodermabrasion

List any prescription creams or oral medications provided by a dermatologist:

Health Information

Check all that apply:
Neck injuriesDental implantPregnantCancerLymph node removedVertigoPacemakerCold soresClaustrophobia

Light Therapy Consultation

Please indicate if any of the following apply to you:
PregnantBreast-feedingEpilepsySeizure disorderPhotosensitive (due to disorder or medication)Currently using steroids

Waiver & Release Policy

I understand I must share my skin and health status truthfully at each Facial Treatment with Erica Coughlin.

I will share any new health or skin information that may have changed upon arrival for each future appointment. I understand that withholding information or providing misinformation may result in contraindications and take full responsibility if so.

I will disclose any injectables including botox and filler that I have received before or in between any treatments from Erica Coughlin.

The treatments I receive here are voluntary and I release Erica Coughlin/Total Wellness With Erica from liability and assume full responsibility thereof for current and future treatments. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I AGREE TO THE ABOVE WRITTEN POLICIES AND UNDERSTAND THIS AGREEMENT AS MY LIABILITY WAIVER AND RELEASE WAIVER FROM ALL TREATMENTS/FUTURE TREATMENTS WITH Erica Coughlin/Total Wellness With Erica.

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