New Client Form

NEW CLIENT INFORMATION & SKINCARE PROFILE
All information given will be kept confidential and only be used by service professionals
Name
Date of Birth

MonthDayYear
Date
Gender
Address

Address

Street Address Line 2

CityState

Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us? If referral, please provide our client's name
Are you pregnant? Due date

MonthDayYear
Date
Check all that Apply
Yes
Yes
Yes
Yes
Yes
Yes
Yes
YesYes
Yes (indoor tanning beds)Yes (outdoor)
Yes
Yes
Yes
Yes
Yes
YesMedical-gradeSpa-grade
YesBotoxFillerLess than 2 weeks ago
Yes
Yes
YesLess than a week ago
YesReacts to some products/ingredients
Do you have any contagious diseases or diagnosed skin conditions? If yes, please list and explain:
Are you currently using any topical face prescriptions, taking medications, vitamins, or supplements? If yes, please list and explain:
Do you have any known allergies? If yes, please explain:
Are you using glycolic/lactic acid (AHA), Salicylic acid (BHA) home products? If yes, what kind?
What is your daily skin care routine?
Which skin care and cosmetic products are you currently using?
What changes would you like to see with your skin? (Your skin goals)
Skin Concerns & Skin GoalsNutrition HealthBoth
YesNoLet’s schedule a Health Assessment Consultation to learn more.Not sure
Yes, please.No, thank you.
Cancellation Policy:

We require a 24-hour notice for cancellations. Less than 24 hour cancellation, there will be a 50% fee charged.

Prior to receiving treatment, I have revealed any conditions that may have a bearing on this procedure, including those listed above and any conditions not listed. I acknowledge and agree to hold Skin Necessities and any contractor/employee harmless against any liability claims for injuries or any other occurrences of events directly caused by the treatment. I have received a thorough explanation of any pre-surfacing and post-surfacing instructions for related treatments. With advanced treatments, redness and/or sensitivity can occur. I understand if 1 should have any additional questions, I will not hesitate to consult with Skin Necessities staff or Tanya Rath.
Client Signature

Clear
Date

MonthDayYear
Date
Professional Signature

Clear
Date

MonthDayYear
Date
Learn more by following us on Instagram:

@skinnecessitiesstudio

@skinhealthchic
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NEW CLIENT INFORMATION & SKINCARE PROFILE

Check all that Apply