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

Month Day Year
Date
Gender
Address

Address

Street Address Line 2

City State

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

Month Day Year
Date
Check all that Apply
Do you smoke?

Yes
Do you have high blood pressure?

Yes
Do you wear contact lenses?

Yes
Do you have a metal implant/pacemaker?

Yes
Do you get cold sores/fever blisters?

Yes
Do you currently have a windburn/sunburn?

Yes
Do you travel by airplane frequently?

Yes
Do you have diabetes? Is it controlled?

Yes Yes
Do you have sun exposure (indoor tanning beds/outdoor)?

Yes (indoor tanning beds) Yes (outdoor)
Do you have any open cuts, abrasions, wounds, active lesions, or open sores?

Yes
Have you ever used any topical prescriptions?

Yes
Have you ever used Retin-A/Retinol?

Yes
Have you ever used Accutane?

Yes
Have you ever had microdermabrasion?

Yes
Have you ever had a chemical peel?

Yes Medical-grade Spa-grade
Have you ever had Botox/filler injections?

Yes Botox Filler Less than 2 weeks ago
Have you ever had laser treatments?

Yes
Have you ever had facial surgery?

Yes
Do you get face wax/electrolysis/use depilatories?

Yes Less than a week ago
Do you consider your skin sensitive?

Yes Reacts 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)
Are you here today for: (check all that apply)

Skin Concerns & Skin Goals Nutrition Health Both
Are you interested in diving deeper into the Skin and Nutrition Health connection and are open to having a Health Consultation to explore what nutrition & lifestyle changes can help increase energy, mood, sleep, balance hormones, result in clearer skin, and lose weight? All with support and accountability?

Yes No Let’s schedule a Health Assessment Consultation to learn more. Not sure
Are you interested in attending our Wellness Support Group called ‘Happy Hour Moms’ to learn more about Nutrition Health and have a safe place to share current health struggles?

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 for Facial Treatments and $25 fee charged for Spray Tan Appointments. No-shows will be charged 100% of the service cost.

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 or Tanya Rath.
Client Signature

Clear
Date

Month Day Year
Date
Professional Signature

Clear
Date

Month Day Year
Date
Learn more by following us on Instagram:

@TanyaRath.HealthCoach &

@SkinHealthNecessities

and on Facebook:

@TanyaRath.HealthCoach &

@SkinNecessitiesSpaSuite

or:

https://linktr.ee/skinnecessities
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NEW CLIENT INFORMATION & SKINCARE PROFILE

Check all that Apply