Client Health History Update

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
You must wait in your car when you arrive to Live by Skin. When you park, please text 339-223-2092 and wait for us to summon you inside. Please do not ring the doorbell, or wait on the porch. Do you confirm that you understand this?* This field is required.Live by Skin can only have one client in the shop at a time. Clients are also not permitted in the shop when we are packing orders, or sanitizing the room. You may not enter until you receive a reply to your text notifying us that you are here.
YESNO
5
Have you started any new medications since your last visit?* This field is required.
Yes
No
6
Is there anything in particular you'd like to focus on in this appointment?* This field is required.
7
Please list new medications below:* This field is required.Please write "n/a" if not applicable.
8
Is there a chance you are pregnant?* This field is required.
YESNO
9
Are you nursing? * This field is required.If you are pumping, please select "yes".
YESNO
10
Are you currently being treated by a physician for any new conditions since your last visit?* This field is required.
YESNO
11
If yes, please list what you are being treated for below.You can write "n/a" if not applicable..
12
Have you had botox or fillers within the past two weeks?* This field is required.Failure to comply with your practitioner's aftercare instructions is a risk. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
13
Do you have botox or fillers scheduled within the next 7 days?* This field is required.You cannot receive botox or filler within 48 hours of a chemical peel or microchanneling. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
14
Have you had any laser treatment, microneedling, laser hair reduction, waxing, or another facial service within the last 4 weeks?* This field is required.Failure to comply with your practitioner's aftercare instructions is a risk. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
15
If yes, please list those treatments and the date of service below.* This field is required.You can write "n/a" if not applicable..
16
Do you have any laser treatments, waxing, laser hair reduction, or another facial service scheduled over the next 14 days?* This field is required.You cannot receive any laser treatments, waxing, or another facial service within 14 days of a chemical peel or microchanneling. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
17
Have you had any form of cosmetic tattooing, microblading, or microblading touch-up in the past 4 weeks?* This field is required.Failure to comply with your practitioner's aftercare instructions is a risk. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
18
Do you have any form of cosmetic tattooing, microblading, or microblading touch-up scheduled over the next 14 days?* This field is required.You cannot receive any microblading, microblading touchup or any facial cosmetic tattooing within 14 days of a chemical peel or microchanneling. We have a 48-hour non-negotiable cancellation policy so please do your homework and make sure you are scheduling your appointments at Live by Skin and other facilities accordingly.
YESNO
19
Have you added any new skincare products to your regimen since your last facial treatment at Live by Skin? Have you stopped the use of or changed anything in your regimen?* This field is required.
YESNO
20
If yes, please list those products below.* This field is required.You can write "n/a" if not applicable..
21
When is the last time you used a retinol or any form of exfoliation?* This field is required.Please select the latest date you used one or both of the above.
Date
Year
Month
Day
22
We cannot perform any treatments on sunburnt skin. Do you guarantee that you do not have a sunburn, or are not healing (or peeling) from a sunburn, on your face?* This field is required.If you show up with a sunburn, we cannot perform a treatment on you and you will be charged 100% of your service due to the held appointment time. This is non-negotiable.
YESNO
23
Did you disclose all changes to your health history?* This field is required.New Health History Information/Update I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform my 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 this institution and/or skin care professional from liability and assume full responsibility thereof.
YESNO
24
Date this form is completed.* This field is required.Date this form is completed.
Date
Year
Month
Day
25
Signature* This field is required.This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read the above information. If I have any concerns, I will address these with my esthetician. I do not hold the esthetician/technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have disclosed all changes to my current health and history.
ClearSignature
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