Returning Client Update Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Please note any changes since last visit. If none, please leave blank
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Health changes?
Medication changes?
Home care product changes?
In the last 5 days have you
Had any waxing performed on your face?
Yes
No
Had any excess exposure to the sun or have been in a tanning bed?
Yes
No
Had any surgical/aesthetic procedures performed (i.e. botox, filler, microneedling, chemical peels)
Yes
No
In the last 24 hours have you used Retin A
Yes
No
What is your number one goal for today's treatment?
**I confirm (to the best of my knowledge) that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: