New Client Card

New Client Card
Name *
Email
example@example.com
Contact Number
Birth Date

Month Day Year
Date
How did you hear about us?
Reason for visit
Do you use

Accutane Retin A Tazorac Differin Other prescription skin products
Have you recently had a

Microdermabrasion Botox Other resurfacing treatments Chemical peel
Do you have any FOOD and/or CHEMICAL allergies, skin sensitivities, or irritants?

No Yes
If Yes, list allergies
Do you use
Skin Type

Sensitive Acne Redness Sunburned Dehydrated Dry Congested Oily
Please list your skin care goals
Pregnant

no yes, how many weeks?
Pace Maker

no yes
Do you suffer from cold sores?

Yes No
Please note any bodily injuries or areas of discomfort
*I understand that if I am using Retin-A, antibiotics and/or a skin bleaching agent it may cause a reaction during waxing services *If skin is tan or sunburned do not get waxed *Avoid sun exposure and tanning beds for at least one full day post wax.
Signature

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