Consultations - Valenti Salon

Thank you for reserving your spa appointment.

To ensure we achieve the optimal results, please complete the following consultation form 24-hours prior to your scheduled spa appointment.

We look forward to seeing you soon!

Dermaplaning

Name *

First

Last

Email *

What would you like out of your visit?

Please check each box next to each statement prior to treatment: *

I understand that Dermaplaning is the process of removing superficial layers of dead skin cells and vellus hair on the skin’s surface by the use of a sterile blade.
I understand that there may be unforeseen risks with Dermaplaning such as nicking, scraping or abrading the skin with the blade.
I understand that possible side effects of the treatment area can include mild redness of the skin, irritation and dryness.
I understand the results of this treatment may vary due to conditions such as age, condition of skin, sun damage, climate, etc.
I understand that direct sun exposure, including tanning beds, is not recommended while undergoing treatment and the use of a daily sun block protection is mandatory.
I understand that any facial injections should be avoided 10 days before this treatment.
I am not using Retin A®, or other retinol derivatives, products containing Alpha Hydroxy Acids (AHA) or Beta Hydroxy Acids (BHA) and have been off these products at least 3 days prior to treatment.

I agree to have this treatment performed on me. I further agree to follow all post-care instructions. Prior to receiving any treatment, I have been candid in revealing any condition that may have a bearing on this procedure. I am over 18 years of age. SIGNATURE: *

Date: *

Lash Extensions

Name *

First

Last

Email *

What would you like out of your visit?

Please check each box next to each statement prior to treatment: *

I understand the possible dangers associated with this eyelash extension application and agree to hold harmless Valenti Salon & Spa and their distributors / instructors harmless from any and all liability, losses, damages, costs or any other expenses which are sustained, incurred or required arising out of the action of the undersigned in the course of my application of eyelash extensions.
I understand that there are inherent risks involved in the eyelash extension application.
I understand that if the extensions are not applied properly by the service provider that there is risk of eye infection, damage or even harm to my vision.
I understand that if I get my extensions wet within the first 24 hours after application, it will compromise the longevity of the extension adhesive.
I understand that I should not pick or rub my extensions at any time and that if I want them removed, they should be removed by a professional otherwise damage or loss of lashes may occur.
I understand that natural lashes shed naturally within a 60 - 90 day cycle and that touch ups are necessary every 2 - 4 weeks to maintain my extensions. I understand that if I do not keep my touch up appointment and it exceeds past the 4 weeks, I will not be eligible for a touch up and a full set must be applied.
I understand that if I use any oil based products it may compromise the longevity of the extension adhesive.
I have read and understood the above information. I have been given the opportunity to ask any questions or concerns that I may have. All of my questions and concerns have been answered to my satisfaction at this time.
I authorize the service provider to perform the eyelash extension procedure.

Date: *

Hydrafacial

HydraFacial is the only hydradermabrasion procedure that combines cleansing, exfoliation, extraction, hydration and antioxidant protection simultaneously, resulting in clearer, more beautiful skin with little-to-no downtime. The treatment is soothing, moisturizing, non-invasive and generally non-irritating. As with most procedures, visible results from HydraFacial will vary from person to person.

What to expect:

Your skin may experience temporary irritation, tightness, or redness. These are all normal reactions that typically resolve within 72 hours depending on skin sensitivity.
You may experience tingling and stinging in the treatment area. These sensations generally subside within a few hours.
Client experiences may vary. Some clients may experience a delayed onset of these symptoms.
You will likely see results immediately after treatment and your skin may feel smooth and hydrated for one to four weeks with appropriate home care to maintain treatment results.
The skin is more susceptible to sunburn/sun damage. Avoid excessive sun exposure and use a minimum of SPF 40 sunscreen.

Name *

First

Last

Email *

What would you like out of your visit?

Do you have any of the following? (Check all that apply) *

Active acne or infection
Open lesion or cold sore
An active infection in the treatment area
Active sunburn
Skin conditions such as eczema, dermatitis, or rashes
An autoimmune disease such as lupus
A viral concern such as HIV or hepatitis
Anticoagulants Therapy
Pregnancy or lactation
Neurological disorders such as epilepsy (LED Lights)
Infection in the urinary system i.e. kidneys, bladder and urethra (Lymphatic drainage)
Crohn’s Disease (Lymphatic drainage)
Hyperthyroidism (Lymphatic drainage)
Deep Venous Thrombosis (Lymphatic drainage)
Lymphedema (Lymphatic drainage)

*Saying yes does not preclude you from receiving treatments.

Have you recently? (Check all that apply) *

Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injectables or laser treatments

I acknowledge the following: *

I will avoid the use of aggressive exfoliation, waxing, and products containing glycolic acids or retinols that are not part of the recommended take-home regimen in the treated areas for minimum 2 weeks pre and post-treatment.
Photos may be taken before, during and after the HydraFacial treatment. Photos will only be used with my written approval for education, promotion or advertising purposes.
The information provided has been explained to me and all my questions have been answered to my satisfaction. I have read the above information, and I give my consent to have the HydraFacial treatment by the staff at Valenti Salon & Spa.

By signing below, I acknowledge that I have read the above information and give my consent to be treated with the HydraFacial System. This consent form Is valid for all future HydraFacial treatments. I will alert the staff If there are any future changes to my medical history. SIGNATURE: *

Date: *

Ultraceuticals

Name *

First

Last

Email *

What would you like out of your visit?

Please advise if you are taking any prescribed medications e.g.: Isotretinon, Warfarin, Chemotherapy medication, thyroid, contraceptive pill, HRT *

Please advise if you are taking any non-prescribed medication or supplements e.g.: Ibuprofen, Asprin, Fish oil *

Please advise of any known allergies: *

Are you pregnant or trying or lactating? *

Do you have any of the following? (Check all that apply) *

Diabetes
Keloid scars
Skin scars
Autoimmune Disease
Cold sores
Haemophilia
Smoker
Wear contacts

Have you recently? (Check all that apply) *

Used Accutane, topical medications or antibiotics
Had aesthetic fillers, injectables or laser treatments

Are you Stressed? Rate your current level between 1 (lowest) to 5 (highest)

Selected Value: 1

What is your current exercise routine & frequency? *

Your current skincare at home: (Check all that apply) *

Cleanser
Serum
SPF
Moisturiser
Exfoliator
Mask

Skincare brand used currently: *

What are the colour of your eyes? *

Light blue or green, grey
Blue, green, grey
Dark blue or green, light brown (hazel)
Dark brown
Brownish black

What is the colour of your hair (naturally and before aging)? *

Red
Blonde
Chestnut or dark blonde
Dark brown
Black

What is the colour of your skin (unexposed areas)? *

Pink
Very pale
Light brown or olive
Brown
Dark brown

Do you have freckles on unexposed areas? *

Many
Several
Few
Rare
None

What happens to your skin if you stay in the sun for an extended period? *

Severe burns, blistering. peeling
Moderate burns, blistering, peeling
Burns sometimes followed by peeling
Rare burns
No burns

Do you turn brown after sun exposure? *

Never
Rarely
Sometimes
Often
Always

How brown do you get? *

Hardly or not at all
Light tan
Medium tan
Dark tan
Very dark tan

Is your face sensitive to the sun? *

Very sensitive
Sensitive
Mildly sensitive
Resistant
Very resistant

How often do you tan? *

Never
Rarely
Sometimes
Often
Always

When did you last expose your skin to the sun or artificial tanning sources (tanning beds)? *

More than three months ago
In the last 2–3 months
In the last 1–2 months
In the last week
In the last day

By signing below, I acknowledge that I have read the above information and give my consent to be treated with Ultraceuticals. This consent form is valid for all future Ultraceuticals treatments. I will alert the staff If there are any future changes to my medical history. SIGNATURE: *

Date: *

Skin Expert Treatment Consideration Checklist

MUST BE REASSESSED PRIOR TO EVERY TREATMENT

Autoimmune disease, diabetes, kidney disease and excessive smoking may increase healing and recovery time

Roaccutane in the last 6 months

Blood thinning medications

Cold sores

Psoriasis, eczema, dermatitis visible

Pregnant, trying to fall pregnant or lactating

Stress levels

Treatment for cancer

History of poor healing or keloid scarring

Medical diagnosis of rosacea

Post skin trauma, discolouration

Recent surgery (within 12 months)

Recent skin cancer removal

Open wounds

Recent sun burn

Laser or IPL within the last 2 weeks

Recent treatments within 2 weeks

Injectables within 72 hours
Facial waxing, electrolysis or use of depilatory creams within 5 days

Commitment to daily use of SPF protection