New Client Form

Personal Information

Todays Date*

MonthDayYear

Full Name*

First NameLast Name

Age*

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone*

Area CodePhone Number

E-mail*

Referred by

Medical Information:

Have you seen a dermotologist in the past five years?*

YesNo

Reason for visit

Have you had cosmetic surgery*

YesNo

When

Type of surgery

Whaty type of skin care products do you use?

Cleanser*

YesNo

Day Moisturizer*

YesNo

Night Moisturizer*

YesNo

Retin A, Renova*

YesNo

Alpha Hydroxy Acid*

YesNoUnsure

Make up*

YesNo

SPF*

YesNo

Please describe any allergies or adverse reaction from a skin care product, cosmetic or skin care treatment. If none put N/A*

Have you taken Accutane for acne in the past three months:*

YesNo

Do you have Eczema, Seborrhea, or Rosacea?*

YesNo

Where

What triggers your flushing

Are there any medical problems we should be aware of (HIV, AIDS, Cancer, etc.)?*

YesNo

If so, please list

When tanning, do you burn easily*

YesNo

Do you have claustrophobia*

YesNo

Do you use oral or topical antibiotics*

YesNo

List current medications or vitamins you are presently taking and reasons. If none put N/A.*

Previous Surgeries. If none put N/A*

In the past five years have you had or used?

Accutane*

YesNo

Acne*

YesNo

Carcinoma*

YesNo

Cold Sores*

YesNo

Diabetes*

YesNo

Latex Allergies*

YesNo

Blood Thinners*

YesNo

High Blood Pressure*

YesNo

Female Specific Information

Are you female?

In Menopause

YesNo

Post Menopaise

YesNo

Pregnant

YesNo

Breast Feeding

YesNo

Birth Control Pills

YesNo

Hormone Pills

YesNo

Hormonal Imbalance

YesNo

Other

Do you smoke*

YesNo

How much?

How long?

Do you have problems with healing or scarring?*

Are you light sensitive?*

Desired treatment area(s)

Last tanning or sun exposure when)?

Have you recently vacationed or are you planning a vacation with sun exposure?*

YesNo

When

What is your skin complexion?

LightMediumOliveDark

Is your skin*

DryOilyCombination

Check all concerns that apply *

Other:

Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skinUnsure

What do you want to improve most about your skin?*

Signature: I have read the above information and have given an accurate account of the questions. *

Date*

Date

Photo/Video

Please be advised that we take photos and/or videos of every client at each session.

Initial:*

Cancellation/Reschedule/No-Show Policy

Your appointments are very important to the entire Journey Skin Company (Co.) family and its affiliates and are reserved especially for you. We understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 48 hours' notice for cancellations.

STRICT AND ENFORCED 48 HOUR CANCELLATION POLICY

Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that appointment time, and other clients miss the opportunity to receive services. As a courtesy, we try to send appointment reminders 2-3 days in advance, however, it is your responsibility to remember the appointment details. Since the services are reserved for you personally, a cancellation fee will apply and a credit card will have to be put on file for future bookings if the cancellation policy is not upheld.

*Cancellations/Reschedules made less than 48 hours prior to an appointment (but not on the day of the appointment) are subject to a charge equal to 50% of the service value.

*Cancellations/Reschedules made on the day of the appointment are subject to a charge equal to 100% of the reserved service amount.

*If an appointment is made the same day and client needs to cancel, the client then must cancel within 4 hours of appointment time, or will result in a charge equal to 100% of the reserved service amount.

*“NO SHOWS” will be charged 100% of the reserved service amount. No exceptions!

The cancellation policy allows us the time to inform our standby guests of any availability, as well as keep our schedule filled, thus better serving everyone. Journey Skin Company (Co.)'s policies are presented and provided in the best quality and tradition of excellent servicing for our established and future client. Thank you for viewing and supporting our policies criteria.

APPOINTMENT CONFIRMATIONS:

As a courtesy, we try to text or email to confirm service appointments 2-3 days prior to your appointment date. Please understand that it is your responsibility to remember your appointment dates and times to avoid late arrivals, missed appointments, and the cancellation fee.

Signature:*

Date*

Date