Client Introduction
For your safety and comfort please provide sincere, detailed responses.
1. Legal Name
*
2. Preferred Name
*
3. Preferred Pronouns
He/Him/His
She/Her/Hers
They/Them/Theirs
Other Please List
4. Date of Birth
*
/
Month
/
Day
Year
Date
5. Phone Number and Email
example@example.com
6. Mailing Address
*
7. Preferred Contact Method Mark only one oval.
Text
Call
EMail
Facebook Messenger
8. Emergency Contact Name and Phone
*
9. How did you hear about Retaliation Aesthetics?
10. What genre of music do you find most relaxing? Check all that apply.
Traditional spa
Soft melodies with lyrics
Instrumentals
Silence please
I prefer to chat during my treatment
11. What concerns do you have about your skin? Check all that apply.
Wrinkles/Lines
Texture
Dull appearance
Pore size or appearance
Discoloration (pigmentation, age spots, redness, blotchiness)
Dryness or Flaky appearance
Excessive oil/shine
Breakouts
Future Issues
Other:
12. What would you like to achieve with today's treatment?
13. Which of the following describes your skin after a day in the sun? Mark only one oval.
I Burns always, tans never
II Burns always, tans slightly
III Burns moderately, tans gradually
IV Burns seldom. tans always
V Burns rarely, tans deep
VI Burns rarely, deep pigment
14. After washing your skin do you experience any of the following? Check all that apply.
Tightness
Burning
Itching
Redness
Other
15. Which products are a part of your current skin care routine? Check all that apply.
SPF
Cleanser
Exfoliant (physical or mechanical)
Moisturizer
Toner
Mask
Prescription topical
Other:
16. If you have had a professional facial before were you pleased with the outcome? Mark only one oval.
Yes
No
Somewhat
17. In the past 12 months have you been under the care of a physician or dermatologist for a chronic or acute ailment? Please detail
18. What prescription medications and/or supplements are you currently taking?
19. Please check any conditions you have been diagnosed with Check all that apply.
Cancer
Hormone Imbalance
Thyroid
High Blood Pressure
Heart Attack, Disease, Problem
Stroke
Hysterectomy
Diabetes
Varicose Veins
Arthritis
Asthma
Eczema
Epilepsy or other seizure disorder
Herpes including herpes simplex (cold sores)
Spinal Injury
Autoimmune Disorder
HIV/AIDS
Lupus
Fibromialgia
Blood clots, poor circulation
Keloid scarring
Skin disease/lesions
Active infection
Other
None
20. Are you currently pregnant? Mark only one oval.
Yes
No
21. Have you ever had Check all that apply.
Surgery
Metal implants
Pace maker
Port
22. Have you ever experienced an allergic reaction? Please detail
23. Have you used any of the following in the last 3 months? Check all that apply.
Retin A
Renova
Adapelene
Deferin
Acid Peel
24. Have you ever been prescribed Accutane medication? Mark only one oval.
Yes
No
25. In the last 30 days have you had Check all that apply.
Dermal Filers (Restylane, Juvederm, etc)
Botox
Laser treatment
Chemical peel
Microdermabrasion
26. Do you wear? Check all that apply.
Contacts
Lash extensions
Permanent cosmetics
Piercings
27. Are you currently utilizing Check all that apply.
Hormone Replacement Therapy
Testosterone
Oral contraceptives
Preview PDF
Submit
Should be Empty: