New Client Card

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

MonthDayYear
Date
How did you hear about us?
Reason for visit
Do you use

AccutaneRetin ATazoracDifferinOther prescription skin products
Have you recently had a

MicrodermabrasionBotoxOther resurfacing treatmentsChemical peel
Do you have any FOOD and/or CHEMICAL allergies, skin sensitivities, or irritants?

NoYes
If Yes, list allergies
Do you use
Skin Type

SensitiveAcneRednessSunburnedDehydratedDryCongestedOily
Please list your skin care goals
Pregnant

noyes, how many weeks?
Pace Maker

noyes
Do you suffer from cold sores?

YesNo
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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