Client Info 2021

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Do you have any allergies? If yes, please specify
Have you had any chemical peels or microdermabrasion treatments in the last six weeks? Yes or No
Have you ever had herpes simplex (cold sores)? Yes or No
If yes, do you have any active sores? Yes or No
Note: Unfortunately, any active sores on the facial area will result in no treatment to decrease the risk of spreading the sore to multiple areas. Let's reschedule!
How did you hear about my services?
May I have consent to take photos for social media? Yes or No
LAST 6 QUESTIONS ONLY FOR WAX CLIENTS - Have you used any retinol, AHA’s, BHA’s, any form of chemical exfoliation or depilatory creams within the last week? If so, please state what you used and the date you used it.
Are you currently on acne medication? If not, have you used any acne medication within the last year?
Do you have diabetes?
Are you currently on any antibiotics or blood thinners?
Have you used a tanning bed within the last 24 hrs?
Do you have a sunburn?
I understand, have read and completed this questionnaire truthfully. 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. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Client Printed Name
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: