New Customer Registration Form

Ruffled Rabbit Esthetics

Client Consultation/Release Form
Full Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Other
Any Allergies?
Select all that apply*

PregnantHeart ConditionsEpilepsyDiabeticHerpesCold SoresChemotherapySkin DiseaseHigh Blood PressureCancerHormone TherapyEczemaPsoriasisN/A
Any health conditions that may affect your treatment?
What supplements, if any, are you taking?
Your daily stress level is:

Mild/LowMedium/AverageHigh/Intense
Are you currently using retinol?*

YesNo
Are you currently taking acne medication?*

YesNo
How often do you wear sunscreen?

EverydayOccasionallyOnly when outsideNever
Do you use tanning beds?

YesNo
Do you smoke tobacco?

YesNo
List any cosmetic procedures/injections you’ve had in the last 12 months
List skincare products you are currently using
How much water do you drink a day?
Do you have metal implants in your body?*

YesNo
What are your areas of concern?

Aging SkinAcneSun DamagePigmentation/RednessPoresize/Surface ConditionIngrowns/Red BumpsOther
How do you prefer your service?
I have read, understand and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in complications in the skin from treatments received. The treatments I receive here are voluntary, and I release Ruffled Rabbit Esthetics LLC; My Beauty Bar or Haley Thonen from liability and assume full responsibility thereof.*

Clear
Should be Empty:

Ruffled Rabbit Esthetics