New Client Intake for Mirla Skincare

Name*

Phone*

e-mail

example@example.com

Mailing Address (optional)

Emergency Contact:*

Emergency Contact Phone:*

Please list any skin care products you are currently using, including makeup:

Any recent surgery, including plastic surgery?

Please explain any recent surgery:

Do you smoke?

Do you sunbathe?

What is your stress level?

Do you experience claustrophobia?

Do you have any metal implants or wear a pacemaker?

Are you pregnant or lactating?

Any complications from Menopause? Please explain

Do you use Retin A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products? If so, please list any that are currently in use:

If you are using any of these products, please do not use any within 3 days of your appointment.

Have you used any of the above products in the past week?

Are you presently using any topical medications? If so, please list:*

Do you have ANY allergies to cosmetics, food or drugs? If so, please list:*

Please describe any important health conditions that you may have:

Do you have any skincare concerns or issues you want to discuss?

I understand, have read and completed this questionnaire truthfully, I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that is is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and skin therapist from liability and assume full responsibility

Client Signature*

Date