Intake Questionnaire:

CoolPeel

Hello
We'd Like To Get To Know You! Please Complete The Following Form​

Your information is confidential and is saved to your account. A copy of this form is available upon request.


Personal Info

Address

Reason For Your Visit

Medical History

Surgery History

Skin History

Aesthetic & Wellness Treatments

Previous Laser Treatments

Skin Type

Treatment Goals

Treatment Planning

Upcoming Events

Topical Numbing

Post-Treatment: Glacial Glide

Beyond CoolPeel

Aftercare Instructions
  • Avoid washing your skin for at least 6 hours after treatment.
  • A sunburn-like effect is normal and may last 24–48 hours.
  • Begin using a gentle cleanser the next day.
  • Okay to apply exosomes and other healing serums the next day.
  • Moisturize frequently using a recommended barrier-repair cream.
  • Wear SPF daily, and avoid direct sun exposure for 2 weeks.
  • Avoid active skincare (retinoids, acids, vitamin C, scrubs etc.) for 5–7 days.
  • Avoid intense heat—including saunas, steam showers, and vigorous workouts—for 7 days.
  • A sandpaper-like texture is expected as your skin heals.
  • Okay to gently exfoliate after 5–7 days — your clear skin will start to show through.
  • Contact us if you experience pain, blisters, swelling, or signs of infection.
  • A Bloom team member will follow up with you 1 week post-treatment.
  • Expect visible results within 7–14 days as your skin heals and collagen renews.
  • A series of 3–4 CoolPeel sessions is recommended for best results.



Current Skincare Routine

Corrective Skincare Ingredients

Preferred Skincare Brands

Allergies

Blood Thinners

Pregnancy & Nursing


Photo Consent


How'd You Find Us

Beverage Preference

BH+ Monthly Membership

HIPAA Privacy Notice
Bloom Health maintains compliance with the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides certain rights and protections to you as the patient, including protection of your Personal Health Information (PHI). HIPAA sets forth rules and restrictions on who has access to your PHI. If you'd like to view our HIPAA policy in its entirety, please click here. By clicking YES below, I acknowledge this privacy notification.


General Consent to Treatment
I verify that I have read and fully understand this questionnaire. I have responded to the questions truthfully. I understand that withholding information or providing misinformation may result in unforeseen side effects or complications. I am aware that it is my responsibility to inform Bloom Health and my treating provider of any updates to my health history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I understand that not all treatments will have the same result for every client, therefore no guarantee can be given. The treatments I receive from Bloom Health are voluntary and I release Bloom Health, PLLC from liability and assume full responsibility thereof.


Informed Consent for CoolPeel

HOME

BH+ MEMBERSHIP

REVIEWS

MAGAZINE

SHOP