Client Consultation

Client Consultation
Name

First NameLast Name
Date Of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Sex
Preferred Pronouns
Who can we thank for sending you in?
Occupation
Health History
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?
If yes, please specify what and when last used
Are you on any medication?
If yes, please specify what and when last used
Have you ever had an allergic reaction to any of the following (Check all that apply)
If yes, please specify
Personal Stuff

Fun things that help me get to know you and personalize your experience
What’s the best thing you've read in the last five years?
What’s the best show on TV right now?
Favorite type of music?
What’s your biggest pet peeve?
How do you like to spend your free time?
What is something people would never guess just by looking at you?
What’s the best piece of career advice you ever got?
Favorite snacks and Drinks?
What do I need to know that could make your time in my studio the best experience possible?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.The treatments I receive here are voluntary and I release this institution and/or the esthetician from liability and assume full responsibility thereof.
Signature
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Client Consultation

Health History

Personal Stuff