Client Consultation, Contraindications, and Documentation
Consent and history
Consultation protects the client and the license. Use a written intake form covering medications, allergies, pregnancy, skin disease, recent procedures, and product use. Explain the service, risks, alternatives, and aftercare, then obtain informed consent. Document objective findings, products, timings, and adverse events. Records should be legible, dated, signed, and retained according to Board rules and prudent practice.
Contraindications
Absolute contraindications mean do not perform: active infection, open lesions, fever, recent surgery in the area, or known allergy to a product. Relative contraindications mean modify or refer: pregnancy, isotretinoin, retinoids, recent chemical peel or laser, diabetes with neuropathy, autoimmune disease, and anticoagulants. When in doubt, get medical clearance, but a note does not erase your duty to assess.
Worked example
A client wants a lip wax. She mentions she started isotretinoin five months ago. Reasoning: isotretinoin thins the skin and impairs healing; waxing can strip skin and cause scarring. The correct response is to decline waxing, explain why, offer an alternative such as trimming, and document the refusal and referral. A quick patch test does not make it safe.
Documentation traps
- Writing client fine without specifics.
- Backdating or altering a note.
- Sharing photos without written consent.
- Failing to record a contraindication you identified.
- Giving medical advice outside scope.
Key habit
Use SOAP: Subjective, Objective, Assessment as an esthetic finding rather than a medical diagnosis, and Plan including service, home care, and referral.