CLIENT FORM

RAW ESTHETICS CLIENT FORM

Please fill out the following form to the best of your ability and let a staff member know if you have any questions while completing this document. The reason for filling out this form is so that we may have a better understanding of your needs to treat you appropriately. All information provided herein is confidential and will not be shared with anyone outside of the Raw Esthetics staff.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
MEDICAL HISTORY

The reason you are being asked to provide information about your medical history is so that your therapist has a full understanding of your physical health to provide you with the most beneficial treatment and avoid any complications. Certain conditions and medications can cause skin sensitivity (particularly drugs that are being used to treat skin conditions, such as many retinoids and antiacne medications including but not limited to Accutane, Retin-A or Differin). If you have any concerns about wether any of our services are safe or appropriate for you due to any medical conditions you have or medications that you are on, please contact your medical provider. Although we may offer our recommendations during your services with us we are not able to medically diagnose or give medical advice. If the question does not apply to you, please respond “NA”.
Please list any medical conditions for which you have been treated for in the past year
Please list any elective or nonelective surgeries that you have had in the past year including chemical peels or laser hair removal
Please list all medications you are currently taking including vitamins and supplements
Please list all known allergies including medication or food allergies
Are you currently pregnant, if so how far along?
MASSAGE QUESTIONS

The following questions are in regards to all body work. Please note following cupping therapy there is the possibility of discolorations or bruise like markings that can occur from breaking up myofascial congestion where the cups were placed. These will dissipate between a couple hour to two weeks following your appointment. If you have any medical conditions or are on any medications and are not sure if cupping therapy is contraindicated or safe for you please contact your medical provider prior to your appointment.
Is this your first time receiving cupping or massage therapy? Do you have any concerns or questions about your appointment?
What would you most like to accomplish with massage therapy? (choose all that apply)

Overall muscular balance and general healthTarget a specific area of concernRelaxation and decompression
Please list any area of pain or discomfort you typically experience. If none please respond with NA
Please select which one best describes your skin type

DryOilyCombinationSensitiveNot sure
SKIN CARE
Please select your 2 primary skincare concerns and/or what you would most like to focus on

AgingHyperpigmentationRosacea/RednessDull SkinOther
What steps do you currently include in you skin care routine

CleanseToneSerumsMasqueMoisturizerLip care or eye careBody Care
What type of cleanser do you prefer?

FoamGelCreamOilNot sure
What type of exfoliation do you prefer?

GentleActiveNot sure
What type of finish do you prefer your moisturizer?

MatteMediumDewyNot sure
WAXING

Please read the following carefully. Waxing under certain conditions that cause skin sensitivity or reactivity can lead to negative side effects when waxing is performed. These negative side effect include but are not limited to skin removal, redness, swelling, and/or tenderness. It is not recommended that waxing should be done if: *You are currently, or have recently, taken any oral or topical medication (especially retinoid, antiacne, or other medications commonly used to treat skin care conditions), skin care supplement, or have had any treatments that could make your skin more sensitive or reactive. Examples include but are not limited to chemical peels, Retin-A, Accutane, Diffiren, and some antibiotics. Consult your physician or pharmacist before waxing to be sure that none of your medications could potentially cause skin sensitivity. *You frequently use tanning beds or are currently sunburned. *You have certain medical conditions, such as diabetes, cancers, or other immune deficiencies or disorders that can lead to a thinning of the skin or skin sensitivity. *(For women) You are currently menstruating or are pregnant, as hormonal changes can affect skin sensitivity. *You have other medical conditions or take any other medications not otherwise listed. It is advised that you consult your doctor before waxing. Those that are prone to skin sensitivity should consult their esthetician prior to any waxing service. If you have any concerns regarding your waxing service, it is advised that you schedule a consultation and patch test with an esthetician.
AKNOWLEDGMENTS

By signing below, you are affirming that you have read and fully understood this form and have answered each question to the best of your ability. Please be aware that it is your responsibility to inform your therapist of any changes that occur after filling out this for so that we may update your client file.
By signing below I acknowledge that the treatment(s) that I receive from the Raw Esthetics Wellness Companies are voluntary and release this institution and/or therapist from liability and assume full responsibility thereof. Client signature required.
If under the age of 18, parent or guardian’s signature required
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RAW ESTHETICS CLIENT FORM

MEDICAL HISTORY

MASSAGE QUESTIONS

SKIN CARE

WAXING

AKNOWLEDGMENTS