New Customer Registration Form

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

E-mail

example@example.com

If a referral please state name:blanks

What are your skincare goals?

Skincare challenges

Have you ever had a facial?

What skincare products are you using?

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? (please keep in mind, if you have used ANY from of retinol in the last 7 days, you will not be able to get any facial service/chemical peel.) *

Have you received any of these hair removal services in the last 30 days? (please keep in mind, if you have received any of the services in the last 7 days, you will not be able to get any facial service/chemical peel.)

If yes please note last time

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? (please keep in mind, if you have received any of the services in the last 14 days, you will not be able to get any facial service/chemical peel.) *

Do you have or had any healthcare conditions?

Do you?

Any known allergies?

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

Have you ever experienced claustrophobia?

Are you pregnant or trying to become pregnant?

Post Facial Care/Waxing/Chemical Peel Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever this can potentially cause damage or compromise your results. Do NOT workout for 3 days after your chemical peel. Limit going in the sun after your chemical peel treatment. Make sure to apply sunscreen, use sun protection, and follow pre and post chemical peel instructions. Do not exfoliate and mask for 7 days after chemical peel. A chemical peel will NOT be preformed on pregnant or breastfeeding women.

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 skin care professional from liability and assume full responsibility thereof.

Signature

Client Consultation / Consent Form

Your Skin