Skin Care Client Profile

Skin Care Client Profile
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Appointment

MonthDayYear
Date
Referred by:*

Google SearchDriving ByGift CardRadioFriend (please list name below)
Referred by (name)*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
In case of emergency contact (name & number):*
Have you had a facial before?*
What are your specific skin care concerns?*

Dry/FlakyAge/Sun SpotsFine LinesExcess OilRedness/SensitivityBlackheadsBreakoutsNoneOther
What skin care products are you using at home?*

CleanserTonerExfoliant/ScrubSerumMoisturizer-DayMoisturizer-NightEye Cream
Brand(s):
Are you pregnant, lactating or plan on becoming pregnant soon?*

YesNo
Are you diabetic?*

YesNo
Do you have any kind of active cancer?*

YesNo
List all known allergies (food, products, ingredients, medication, etc)*
Have you ever had a reaction to skin care products or ingredients?*

YesNo
If yes, please explain
Are you using any prescribed exfoliants? (Retin-A, Differen, Renova, etc)*

YesNo
How often?
Are you under the care of a doctor for an auto immune disorder?*

YesNo
Are you currently taking any medication that could interfere with a facial treatment?*

YesNo
If yes, please explain
How many ounces of water do you drink daily?*
On average, how many hours of sleep do you get each night?*
On a scale of 1-10, what is your current stress level? (10 being highest)*
Do you take vitamins / supplements?*

YesNo
I understand that redness, sensitivity, peeling or other reactions may occur from facial treatments. If I experience any discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that estheticians are not qualified to diagnose, prescribe, or treat any disease or illness and that a facial should not be a replacement for medical treatment. The treatments I receive here are voluntary and I release the Spa at Springfield / Dolce Medical Spa or skin care professional from liability and assume full responsibility thereof.
By typing my name below, I acknowledge this document.*
Date*

MonthDayYear
Date
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