ANATURALE CONSULTATION FORM

CONSULTATION FORM
Name*
Address*
Zip*
Phone*
Email*
example@example.com
City*
State*
Occupation*
Date of Birth*
Sex: Female Male*
Preferred Method of Communication:*

E-mailPhone
Emergency Contact*
Phone*
How were you referred to us:*
Name your referral
1. Name your level of Stress from 1 to 5 highest
2. What physical activity you enjoy?
3. Do you wear Contact Lenses:
4. Allergic to Aspirin YES or NO Skin Sensitivity/General Allergies? YES o NO
5. Do you smoke? YES or NO if yes, how many cigarettes per day?
6. Please list any accidents or surgeries in the last 12 months
7. Did you have any metal implants and or body piercings?
8. Did you have a pacemaker ?
8. List the Medication (s)/Supplement (s) you are currently taking
9. Are you currently taking any of the following

Birth controlAntibioticsBirthcontrolHormone ReplacementBlood ThinnersN/A
HEALTH HISTORY - Please check all that apply
Please write N/A if none Apply here
ArthritisIrregular digestionHerpes Simplex VirusMRSAAllergy to iodine/or ShellfishCirculatory ProblemsHypertensionEye Infection/DisorderChronic PainOsteoporosisSleep ProblemsVaricose VeinsHeart DiseaseEpilepsySerious Sunburn or ExposureDiabetesClaustrophobiaEczema/PsoriasisSciaticaHyper/Hypo ThyroidFacial WartsHeadachesKeloid/Hypertrophic ScarsSun Alergy
10. Have you ever been diagnosed with Cancer? YES NO (if yes, please complete our Oncology
YES
NO
11. Are you pregnant/nursing or trying to become pregnant ?
12. Any other medical conditions or concerns we need to know about?
CONSULTATION FORM
13. Are you under the care of a Dermatologist?
14. Do you use any of the following?

Scrub or PeelAccutaneRetin-ARenovaAdapalaneResorcinolN/A
14. Have you had any of the following?

Chemical PeelMicrodermBotoxDermal FillersTreadsFraxelLasersLaser Hair ReductionPermanent CosmeticsDermaplaningN/A
Other resurfacing treatments, please be specific:
Any serious side effects?
16. Are you currently using any of these products that contain the following?

Glycolic AcidLactic AcidHydroxy AcidVitamin AVitamin CN/A
SKIN MAINTENANCE/ Products Used- List Brand and Frequency of Use
17. Skin Type and or Condition?

Oily/CongestedDry/DehydratedSensitive/RednessAcneSunburnN/A
18. Have you been tanning in the last 24 hours?

yesNo
19. In the last week have you had Waxing or Electrolisis?
Waxing
20. What are your skin care goals?
21. Products used/brand?

Cleanser/SoapTonerExfoliatorMoisturizerSPFSerumsMasqueN/AOther
CONSULTATION FORM
It is my choice to receive skin treatments, including skin care, hair removal or microdermabrasion. Because massage/bodywork, skin care and other treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I will update Anaturale Skin Care Studio of any changes to my health status. I understand that Estheticians do not diagnose illness, disease, or physical or mental disorders, nor do they prescribed medical treatments, pharmaceuticals, and that nothing said in the course of the session given should be construed as such. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during the session, I will immediately inform the Esthetician so that the service may be adjusted to my level of comfort or discontinued. I could experience varying degrees of redness, burning, peeling, itching, etc., especially in the initial stages of a skin program. I further understand that I am paying for a treatment and not a result and that there will be no returns, refunds or exchanges.

If I am unable to make a schedule appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case I will call ASAP ro reschedule my appointment. If I miss a schedule

appointment without giving 24-hour notice, I agree to pay the missed appointment fee that applies. Initial
Here
I understand that any elicit or sexually suggestive behavior, remarks or advances made by me will result in the immediate termination of the session and I will be liable for payment of the scheduled service. Further, I understand that Anaturale Skin Care Studio reserves the right to refuse to administer services at their sole discretion. I have read and fully understand this form in its entirety. I hereby release the practitioner, Anaturale Skin Care Studio and their insurers, and their respective officers, directors, successors, employees, and agents from all liability of any nature whatsoever, whether past, present, or future, for injury or damage which may occur to myself or my family as a result of my receiving skin care (facials, peels), microdermabrasion or hair removal services.
Client Signature

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The information I have provided is accurate and true.
Client Signature

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CONSENT TO TREATMENT OF MINOR: by my signature below, I authorize ANATURALE Skin Care Studio to administer facial techniques to my minor child or dependent as they deem necessary or proper.
SIGNATURE

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LE Signature/Provider

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Should be Empty: