New Client Form for skin care

Name *
Date of Birth *
Date of Birth
Phone *
Address *
Does your job require that you work outdoors? *
Your Skin Care
Have you ever had a facial treatment before? *
If so, when?
If so, when?
You can give an estimate date
Which of the following best describes your skin type? (Please circle one type number) *
Have you ever had chemical peels, laser or microdermabrasion? *
If yes, was it done within the last month?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *
Have you used an acne medication? *
List products such as soap, toner, mask, eye product, cleanser, day moisturizer, exfoliator, scrubs, shower gels, body lotions, sunscreen SPF, night moisturizer/cream, makeup products, and any others.
Have you recently used any self-tanning lotions, creams or treatments?
Have you used any of the following hair removal methods in the past six weeks?
Check all that apply
What areas of concern do you have regarding your skin?
Check all that apply
What areas of concern do you have regarding your eyes?
Check all that apply
What areas of concern do you have regarding your lips
Check all that apply
Have you ever had an allergic reaction to any of the following?
Check all that apply
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Have you experienced Botox, Restylane or Collagen injections?
Do you have a pacemaker or other internal metal device? *
Are you currently taking any medications? *
Female Clients Only
Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatment?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?
Are you undergoing any hormone replacement therapy?
Male Clients Only
What is your current shaving system?
Do you experience irritation from shaving?
May I call you at phone number you provided to confirm future appointments?
May I contact you via mail/email about future promotions and news?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.