MEDICAL HISTORY AND CONSENT

Date

Name

Birth Date

Age

Address

Gender

Phone #

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact

Number for Emergency Contact

Format: (000) 000-0000.

Are you presently taking any medications, including birth control?

If yes to the above question please list medications

Do you have allergies to cosmetics, medications or foods?

If yes to the above question please list

Please select from the list below which illnessess you curently or have previously suffered from

Please select which of the following products you have used within the past 3 months

Do you consume alcohol

Do you smoke

Do you exercise regularly

Have you ever had a facial/vajacial treatment before?

If yes to the above question, please indicate when

Please select which of the following hair removal methods you have used in the past 6 weeks

In the past 30 days, list all professional facial or dermatology services you have received ( ie chemical peel, microdermabrasion, laser, Botox, other cosmetic injectables)

Please select your skin type

What skin care products do you currently use?

What are your skin care challenges?

I affirm that I have stated all my known medical conditions and all of the above information is true and accurate to the best of my knowledge. I take full responsibility for alerting my esthetician to any physical or mental condition which would affect my service or results. I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability to skinfinity or its estheticians should I fail to do so. I understand my treatment is therapeutic in nature and will alert my esthetician to any discomfort. I understand the treatment and accept any risks. I hereby release skinfinity from all liabilities associated with my treatment. I agree that this consent supersedes any previous verbal or written disclosures. This consent is valid for all of my treatments in the future as well.

Client Name (Print)

Signature

Date

LIFESTYLE