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
no
If Yes, to what?
YesNo
heart diseasestrokelow/high blood pressureblood clothshemophiliadiabetesepilepsycancerherpesasthmaOther
yesno
yesnoOther
NoYesOther
pregnantbreastfeedingtaking birth controlmenupauseOther
COSMETIC HISTORY
Have you undergone plastic surgery? If yes, what area(s) and when*
noOther
laser treatmentsfacial treatmentsskin tighteningOther
Date of Treatment

MonthDayYear
Date
Area(s) of treatment
LIFESTYLE
Occupation*
any specific diet? (vegan, keto, lactose etc)
Do you take any supplements/vitamins?*
coffeealcoholsmoke
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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CLIENT CONSULTATION FORM