LaHood Esthetics - General Consent

17 S. 5th St. Suite 1 Bozeman, Montana 59718 | 406.551.6506 | www.lahoodesthetics.com

Thank you for choosing LaHood Esthetics! We so appreciate you taking the time to fill out the following form to ensure that we provide you a safe and effective service.
CONTACT INFORMATION
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MonthDayYear
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Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone
Email
example@example.com
Address

Address

Street Address Line 2

CityState

Zip
Emergency Contact
Relationship
Emergency Phone
Format: (000) 000-0000.
How were you referred to us?
MEDICAL HISTORY
YESNO
If yes, for what?
YESNO
If yes, for what?
CancerThyroid ImbalanceKeloid ScarringHigh Blood PressureFrequent Cold SoresSkin Disease/Skin LesionsHerpesRosaceaHepatitisHIV/AIDSDiabetesBlood Clotting AbnormalitiesSkin CancerSeizure DisorderArthritisHormone ImbalanceAny Active Infection
YESNO
Do you have any other health problems or medical conditions? Please list
FOR OUR FEMALE CLIENTS
YESNO
YESNO
YESNO
ALLERGIES
FoodLatexLidocaineAspirinHydrocortisoneHydroquinone or skin bleaching agentsOther
If yes, describe the reaction you had.
YESNO
YESNO
Please list any fragrances with issues
MEDICATIONS
Please list all medications you are currently taking
Topical medications
Vitamin/Herbal Supplements
YESNO
If yes, when did you last use it
HISTORY
YESNOI don't know
If yes, please list the product(s) name
ShavingWaxingElectrolysisPlucking/TweezingThreadingDepilatories
YESNO
YESNO
YESNO
YESNO
If yes, please describe
LIFESTYLE
Occupation
Hobbies/Activities
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the Esthetician, Technician, Therapist, Doctor or Nurse of my current medical and health history and to update any current conditions. A current medical history is essential for the caregiver to execute the appropriate treatment procedures. (All information is strictly confidential)
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CONTACT INFORMATION

MEDICAL HISTORY

FOR OUR FEMALE CLIENTS

ALLERGIES

MEDICATIONS

HISTORY

LIFESTYLE