New Client Questionnaire

New Client Questionnaire
Time to take Revenge against all things Anti-beauty, but first, tell me a little bit about yourself!

New Client should complete the following, as directed, as thoroughly and in as much detail as possible.
Today's Date*

MonthDayYear
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Emergency Contact/Relation to Contact/Phone Number*
Medical History: Are you currently, or have you previously experienced any of the following?*

Heart ConditionPace MakerHeadachesAnemiaLow blood pressureCancerThyroid ConditionKidney ProblemsHigh blood pressureArthritisHemophiliaAsthmaDiabetesHypo/Hyper glycemiaHepatitisHerpes SimplexAIDS/HIV PositiveAutoimmune DiseaseOther
If you are currently experiencing or being treated for any health-related condition please describe:*
If this does not apply please enter N/A.
Have you ever had a surgical or non surgical procedure? If yes, where on your body was the surgery performed?*
If this does not apply please enter N/A.
Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side-effect:*
If this does not apply please enter N/A.
Please list all over-the-counter and prescription medications you are currently taking:*
If this does not apply please enter N/A.
Please indicate if you have ever used any of the following medication for skin treatment:*

AccutaneCortisoneStaticinBenzoyl PeroxideRetin ASulferDesquamXZeracFosdexGlycolic AcidSalicylic AcidLatic AcidRenovaClindamycinTazorateneMetrogelOther
If you selected any of the above, what condition were you treating with this medication and when was the last time of use?*
If this does not apply please enter N/A.
How did you hear about Rich Revenge Beauty?*
Are you Pregnant?*
Are you planning a pregnancy in the near future?*
Are you on any type of hormone therapy? If yes, please describe:*
If this does not apply please enter N/A.
Do you have regular menstrual cycles? *
Are you going through menopause?*
Do you have any hormone imbalance?*
Have you undergone surgical menopause (hysterectomy)?*
If you have had a hysterectomy, please disclose when:*
If this does not apply please enter N/A.
Do you come in contact with any chemicals at work?*
Do you work around excessive heat or cold?*
Use hot tubs/sauna?*
COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation measures this business has always adhered to, new preventative measures that have been put in place to further reduce the spread of this noval coronavirus. However, these best practices still offer no guarantee regarding your potiental risk of being infected.
Covid-19: Have you had a fever in the last 24 hours of 100 degrees Fahrenheit?*
Covid-19: Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath?*
Covid-19: Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus type symptoms?*
For documentation purposes, before and after photos will be taken. Please provide consent for these same photos to be used for advertising purposes.*
*By signing, I understand and agree to the Late and Cancellation Policies, and that I am ultimately responsible for payment in full for services received and/or scheduled. I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any claims related thereto. I give my consent to receive treatment from Rich Revenge Beauty, LLC.*

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New Client Questionnaire

Time to take Revenge against all things Anti-beauty, but first, tell me a little bit about yourself!