Client Introduction

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
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
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