Existing Client Update/Treatment Record

Existing Client Update/Treatment Record
Date*

MonthDayYear
Date
Name*

First NameLast Name
Please note any changes of the following since your last visit:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Health/Medications
Skin Care Products
Hormones (women only)
In the last 5 days have you...
Had any waxing or depilatories in the area being treated?*
Had any excess exposure to the sun?*
Been in a tanning bed?*
Been ill?*
Had any surgical/aesthetic procedures?*
In the last 24 hours have you...
Exercised?*
Used Retin-A?*
What are your plans for the rest of the day?*
What are your plans for the next 7 days?*
* By signing, I am stating that I have provided the information above to the best of my knowledge.*

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