Skin Care Consultation Form
Todays date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Cell Phone Number
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Area Code
Phone Number
Home Phone Number
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Area Code
Phone Number
Email
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example@example.com
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
What are your main concerns or goals?
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Do you have any allergies?(list all environmental, foods, and medicines)
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Select your skin type
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I Creamy complexion Always burns easily, never tans
II Light Complexion Always burns, tans slightly
III Light/Matte Complexion Burns moderately, tans gradually
IV Matte Complexion Seldom burns, always tans well
V Brown Complexion Rarely burns, deep tan
VI Black Complexion Never burns, deeply pigmented
Have you had any of these health conditions in the past or present?(Please check all that apply and provide additional information in the space provided)
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Cancer
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart problem
Asthma
Eczema
Epilepsy
Seizure disorder
Fever blisters
Headaches (migraines)
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
artificial joints, pins or plates
Phlebitis, blood clots, poor circulation
Blood clotting abnormalities
Psychological treatment
Keloid scarring
Skin disease/skin lesions
Any active infection
hormone replacement
Oral Chemotherapy
Radiation therapy
Chemotherapy
Immunotherapy
None of the above
List all medications you are currently taking
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Are you currently under Doctors care for Skin cancer? (what type)
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Do you spend time in the sun? Do you participate in outdoor activities?
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Do you apply sunscreen daily?
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What products are you using?
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Do you use any of the following Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
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Yes
No
I acknowledge that I will stop all retinols and exfoliating products prior to Skin care treatments or waxing services. I understand that failing to stop products prior to skin care resurfacing treatments and waxing services can cause lifting of the skin and irritation.
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yes
no
Have you ever had a facial?
Yes
No
Have you ever had any of these peels?
Glycolic
Lactic
Salicylic
Jessner
TCA
VI Peel
Perfect Peel
Blue Peel
None of these
Have you ever had a bad experience or reaction? Please explain.
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I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous 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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Please verify that you are human
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My digital submission is my acceptance and agreement
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I understand that I could experience an allergic reaction to the products used on my skin, though it is rare and nor predictable. I agree to release the esthetician and business from any and all liability. I agree to seek medical attention from a dermatologist or urgent care facility immediately.
Signature
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Submit
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