Top Self Maintenance

Top Self Maintenance

Hamilton
CLIENT CONSULTATION FORM
Name
Birthday
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postal
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Contact #
How Did You Hear About Us/Who Referred You?
MEDICAL HISTORY
Do you have any allergies?
If Yes, to what?
Are you currently under the care of a Doctor or Dermatologist for a Medical Condition
Please select any condition that you have been diagnosed with and/ or for which you are receiving treatmet

Other
Do you/have you ever taken: Accutane?
Are you using any accutane and active ingredient product (retinol, glycolic, AHA, BHA, salicylic, hydrocortisone)

Other
Do you have any metal implants, pacemaker, pin, tattoos

Other
(women) are you...

Other
COSMETIC HISTORY
Have you undergone plastic surgery? If yes, what area(s) and when
Have you had/currently have injectables (botox, fillers, dysport)? if yes when?

Other
Have you previously had cosmetic treatments (or are currently undergoing):

Other
Date of Treatment

MonthDayYear
Date
Area(s) of treatment
LIFESTYLE
Occupation
any specific diet? (vegan, keto, lactose etc)
Do you take any supplements/vitamins?
do you consume:
SKIN CARE & WELLNESS
do you exercise regularly? what kind and how often? (ex. yoga 2 times a week)
What is the reason for your appointment with us?
what are your skin concerns? (ex: oily skin, acne, uneven skin tone, large pores, fine lines, flaky skin,)
HOME CARE REGIME
what are you currently using for your skin care products? (please list your products and brands)
I hereby state that any and all information I have provided is accurate, the risks have been explained to my satisfaction prior to signing and I freely consent to the treatment(s
All information provided within is confidential
Signature
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Top Self Maintenance

CLIENT CONSULTATION FORM

MEDICAL HISTORY

COSMETIC HISTORY

LIFESTYLE

SKIN CARE & WELLNESS

HOME CARE REGIME