Pretty Please Haus of Vanity

Date*

Date

Name*

First NameLast Name

Pronouns

Date of Birth *

Date

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral

If referred, by who?

Are you currently under the care of a physician?*

YESNO

Have you experiences any of these health conditions in the past or present?

Any known allergies?*

Medications/supplements you are currently taking.

Have you ever received any botox or fillers? if so, where and when?

Have you ever experienced claustrophobia?

YESNO

Please rate your stress level

LowMediumHighNone

What are your skin concerns?

Ethnic Background

What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)

What skin care products do you use on a daily basis?*

Do you experience routine breakouts or acne?

YESNO

Have you been diagnosed with eczema, psoriasis or rosacea?

YESNO

Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis

Do you currently use:

AccutaneRetin-APrescribed topical cream

If YES, please specify which product or type

Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO

Do you?

Are you taking birth control?

YESNO

Are you pregnant or breast-feeding?

YESNO

I acknowledge that I must adhere to Pussy Willow Esthetics’s policies. I understand that cancellations must be done with at least 24 hours notice. If I do not cancel before 24 hours, I will be considered a no-show and will be responsible for paying 50% of the service price. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the no-show policy.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Pussy Willow Esthetics and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Pussy Willow Esthetics

Medical History

Your Skin