Disclaimer:
This form only needs to be completed once before your FIRST visit. If there are no new medical changes, you do not need to fill out this form again.
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Date of Birth:
Check the conditions that apply to you.
*
Radiation or Chemotherapy
Pacemaker
Metal Implant
History of Stoke
Epilepsy/ History of Seizures
Pregnant or Lactating
Bell's Palsy
Lupus
AIDS/HIV
Hepatitis B (HBV)
Hepatitis C (HCV)
Asthma
None of the above
Any other medical conditions:
*
Are you currently taking any medication?
*
Yes
No
If so, what medications?
*
Do you have any allergies?
*
Yes
No
Not Sure
If so, what are they?
*
What is your Gender?
Male
Female
Other
Do you use tanning beds?
Please Select
Yes
No
Have you ever had a reaction to any facial products before? If so, what and please explain.
*
Have you had a facial before?
Yes
No
Facial Procedures and History
Microdermabrasion
Chemical Peels
Dermaplaning
Microblading, Microdshading, Permanent Makeup
Facial Laser Treaments (BBL, IPL, Fractional Laser, Laser Hair Removal, etc.)
Facial Waxing
Botox/Dysport
Filler
Facial Surgery
Kybella
Microneedling
Microchanneling
Other
If yes to any of the above, please list dates if within the last year.
*
Are you currently taking Accutane or any other oral/topical medications prescribed by your doctor? If yes, please list below.
*
Your current AM/PM skincare routine, if you have one:
Please select all skin concerns/how you would describe your skin:
*
Acne
Large Pores
Scarring
Melasma
Hyperpigmentation
Hypopigmentation
Dullness
Dehydrated
Dry
Fine Lines/Wrinkles
Blackheads
Texture
Loss of Firmness
Psoriasis
Rosacea
Eczema
Milia
Oily
Combination
Sensitive
Sundamage
Normal
What are you hoping to improve on?
*
How did you hear about Vain Skin Studio?
Are you comfortable with your photos being posted on Vain Skin Studio's social media and website?
*
Please Select
Yes
No
I understand that I must give at least a 48 hour cancellation notice. If I fail to cancel before 48 hours of my scheduled appointment I will be charged 50% of my scheduled service. I understand that if I fail to show up to my scheduled appointment without any communication I will be charged 100% of my scheduled service. I understand that if I become a habitual offender I may be required a 100% non refundable deposit to schedule an appointment or may be refused service.
*
I have answered all of the above questions to the best of my knowledge.
*
Submit
Should be Empty: