Name
First Name
Last Name
Date of birth/Age
Email
example@example.com
Would you like to receive emails from The Tailored Aesthetic?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of contact
Call
Text
Email
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Skincare goals and/or concerns
Model Release
I give permission to The Tailored Aesthetic to use photographs taken for social media, advertising or promotion.
Yes
No
Photos only for chart purposes
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Medical History
Please select any of the following health concerns you currently have or have had:
Cancer
Diabetes
Epilepsy
Hormone Imbalance
Blood Disorder
Thyroid Condition
Hepatitis B or C
HIV/AIDS
Tuberculosis
Heart Condition
Immune Disorder
Have you seen a dermatologist within the last year?
Please Select
Yes
No
Are you prone to getting fever blisters?
Yes
No
Please list any allergies you have:
Please list any medications you are currently taking:
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Skincare History
Have you ever had facials, chemical peels, laser treatments or microdermabrasion? If yes, when?
Please list the skincare products you are currently using:
Are you using any form of vitamin a? If yes, what are you using and when is the last time you used it?
Is your skin prone to being red?
Yes
No
Do you burn easily in the sun?
Yes
No
Is your skin susceptible to scarring or keloids?
Yes
No
Do you wear SPF daily?
Yes
No
Please sign & submit
Submit
Should be Empty: