Skin Treatment Form

1
Client's Name
First Name
Last Name
2
Gender
Male
Female
3
Phone Number
4
Email Address
example@example.com
5
What are your current skin concerns?
6
Do you have any of the following conditions? If yes, please select them:select all that apply
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV AIDS
Hepatitis A/B/C
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
nut allergy
history of cold sores
Claustrophobic
Other
7
Skin Type
Normal
Oily
Dry
Acne
Sensitive
combination
rosacea
Other
8
Please list any allergies or sensitivities.example: Lavender, specific ingredient, honey, etc
9
How does your skin heal?
Fast
Pigments
Scars
Slow
Other
10
What is your current homecare routine?
11
Do you smoke?
Yes
No
12
Are you pregnant?
Yes
No
13
Are you trying or planning to be pregnant?
Yes
No
14
Are you breastfeeding?
Yes
No
15
Please list medications currently taking.example: Blood thinners, retin-A, oral contraceptives etc..
16
Are you wearing any contact lenses?
Yes
No
17
Are you currently under a doctor or dermatologist's care?
Yes
No
18
If so can you briefly explain.
19
Terms and Conditions* This field is required.I understand that my data will be strictly confidential. I confirm that all information in this form is true and accurate. I hereby release all liability for services rendered by Melissa Villados. This includes all services performed during my treatment and hereby promise to follow all aftercare recommendations. I assume full responsibility for adverse reactions, injury and release Melissa Villados from full liability for all services performed while undergoing all services.
20
Client Signature* This field is required.
21
Date Signed
Date
Month
Day
Year
Should be Empty: