Ruffled Rabbit Esthetics
Client Consultation/Release Form
Full Name
*
First Name
Last Name
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
How did you hear about us?
*
Please Select
Instagram
Website
Facebook
Other (Please specify...)
Other
Any Allergies?
Select all that apply
*
Pregnant
Heart Conditions
Epilepsy
Diabetic
Herpes
Cold Sores
Chemotherapy
Skin Disease
High Blood Pressure
Cancer
Hormone Therapy
Eczema
Psoriasis
N/A
Any health conditions that may affect your treatment?
What supplements, if any, are you taking?
Your daily stress level is:
Mild/Low
Medium/Average
High/Intense
Are you currently using retinol?
*
Yes
No
Are you currently taking acne medication?
*
Yes
No
How often do you wear sunscreen?
Everyday
Occasionally
Only when outside
Never
Do you use tanning beds?
Yes
No
Do you smoke tobacco?
Yes
No
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?
*
Yes
No
What are your areas of concern?
Aging Skin
Acne
Sun Damage
Pigmentation/Redness
Poresize/Surface Condition
Ingrowns/Red Bumps
Other
How do you prefer your service?
Please Select
Light Conversation
No Conversation
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.
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