Medical & Skin Histology

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:
ex. 555-555-5555
Birthdate:
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
Who referred you to MD ESTHETICSTRY?

Preparing for your appointment:

Please bring all of the products you currently use to your appointment, or fill them in below. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will be added. Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin. This regimen must be used in order to continue treatments at MD ESTHETICSTRY, however not all products must be purchased on your first appointment.
Current skin care products you use at home. Include brand names and product names.
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 it 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 MD ESTHETICSTRY and/or the skin care professional from liability and assume full responsibility thereof.*

I understand the cancellation policy.
MD ESTHETICSTRY strictly enforces our 24-48 hour cancellation policy as a courtesy to our staff & clients. NO CALL NO SHOW will have the full balance of that scheduled service charged to your credit card or forwarded to your next appointment, at MD ESTHETICSTRY’s discretion. Cancellations made in 24 hours or greater will not be penalized.*

I understand the cancellation policy.
OPTIONAL: I grant permission to MD ESTHETICSTRY to use photos of my progress for marketing purposes www.mdestheticstry.com or other business listing pages such as Instagram.

I grant permission.
Date*

MonthDayYear
Signature*

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Medical & Skin History