Skincare Health History Form (facials / dermaplaning / waxing)

Skincare Health History Form (facials / dermaplaning / waxing)

To be used to analyze your skin for facials, waxing or dermaplaning services
NAME

First NameLast Name
Email
example@example.com
Please list address for marketing and /or coupons ~ Optional

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
What are your skin concerns*

Sun Spots/ Brown spotsRednessFirming/WrinklesAcneVellus HairSensitivitesNo ConcernsOther
Are you pregnant?*

YESNO
Are you nursing?

YESNO
Do you have an active cold sore?*

YESNO
Please list any allergies to medications, foods or products, as they may affect your services with me. List "NONE" if you have no allergies to medications, products, foods -etc.
List allergies / or state "NONE"
Waxing, microdermabrasion, dermaplaning or chemical peels will make your skin sensitive to the sun and will require sunscreen every 90 minutes or as instructed on your sunscreen bottle
Attention: Accutane clients must be off for one year to wax, and retinol off 7 days. Peels must wait 14 days for waxing or dermaplaning. Laser or resurfacing (six-month minimum wait for waxing or advanced esthetics). Caution: Aspirin (will thin your skin, as well as diabetic medications & blood thinners). Please list any over the counter products or prescription medications you are taking and/or procedures in the last six months. State "NONE" if this does not apply.
List medications / procedures or state “NONE”
By signing this form, you are authorizing Serendipity Salt & Skin Spa / DBA Serendipity Massage & Skin Spa, licensed Esthetician, Liane McWilliams to analyze and treat your skin concerns. *If anything changes in your allergies, medications, health or OTC products please advise me in writing, by updating this health history form. You are releasing Serendipity from any liabilities. You further understand there is a 24-hour cancellation policy in place, or $35 fee will be placed on your account. No shows are charged 100% and blocked from booking until payment is made. Thank you for understanding this policy.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: