Facial Health History Form

What skin care product/ingredients are you using at home?

Glycolic Acid Retin-A, Retinol/Vitamin A Deferin gel Lactic Acid Salicylic Acid Any topical or Oral acne medications
List any skin care products that you use at home. i.e. brand, face wash, moisturizer, serums, spf?
Amount of water that you drink daily
Any current medical conditions? Please list
List any medications? i.e. antibiotics, high blood pressure meds, any Rx.
Any allergies? i.e. foods, medicine, Iodine
Have you ever had a reaction to any skin care products? i.e. Rash, breakout, irritation.
Have you had any surgery, including plastic surgeries, within the past 12 months?
What are your skin concerns, if any?
Feel free to add any photos of your skin or skin care products here.

Browse Files

Cancel of

I am over the age of 18 years old *

Yes No
*If you are not 18 years of age, you will be required to have a parent or guardian present at the time of your appointment.
Renewed Skin and Body Cancellation policy is as follows:

A credit card is required to book your appointment, this card holds your appointment. In the event that you no-show or late cancel your appointment less than 24 hours before your appointment time, your card will be charged a fee. Fees vary depending on the appointment(s) booked.

Inputing your card during the booking process, does not pay for your service(s), it simply holds your apoointment
Initial that you understand the cancellation policy *
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that supersedes any previous verbal or writen disclosures. I understand that withholding information or providing misinformation may results 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 Renewed Skin and Body and/or the skin care prfessional from liabilty and assume full responsibility thereof. I understand that before and after picutures may be take during your appointment, your service provider will ask if it is ok before the pictures are taken.
Date

Month Day Year
Date
Signature *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Renewed Skin and Body

Health History Form for Facial Services