CLIENT INFORMATION & MEDICAL HISTORY & PHOTO RELEASE

CLIENT INFORMATION & MEDICAL HISTORY & PHOTO RELEASE

384 Inverness Pkwy, Suite 130, Englewood, CO
In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is strictly confidential and is not shared or sold to anyone.
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Age
Occupation
Address

Home Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip Code
Email
example@example.com
Mobile Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
How were you referred to us?
Emergency Contact Name, Phone, and Relationship to Client
Always Burn, Never TanAlways Burn, Sometimes TanSometimes Burn, Always TanRarely Burns, Always TanBrown, Moderately Pigmented SkinBlack Skin
Are you currently under the care of a physician? Yes or No If Yes, Who?
High Blood PressureHerpes 1 or 2ArthritisFrequent Cold SoresHIV/AIDSKeloid ScarringSkin DiseaseSeizure DisorderHepatitisHormone ImbalanceThyroid ImbalanceBlood ClottingAny Active Infection
Are you currently under the care of a dermatologist? If yes, for what:
Do you have any other health problems or medical conditions? Please List
FoodAspirinLatexHydrocortisoneHydroquinoneSkin Bleaching AgentsAnesthesiaOther
If you checked any above boxes, please describe reaction
What oral medication are you currently taking?
Are you on any mood altering or anti-depression medication?
Have you ever used Accutane? If yes, when did you last use it?
What topical medications or creams are you currently using?
What herbal supplements are you currently using?
yesno
yesno
ShavingWaxingTweezingThreadingDepilatories (chemical hair removal)
yesno
yesno
yesnounsure
yesno
If you answered yes above, please describe.
Do you have a skincare regimen at home? If so please list products, brands and any other information that may helps us.
For Our Female Clients :
yesno
yesno
yesno
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform Source Skincare, LLC and its Estheticians, of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Signature*
Date*

MonthDayYear
Date
PHOTO RELEASE FOR MARKETING/SOCIAL MEDIA:

I give Source Skincare, LLC and it's practictions permission to take photos/videos of me before, during and after any procedure in order to use for online marketing, on paper marketing or on social media, such as Instagram, Facebook, Google, Twitter or any of the like. I am aware that my photos/videos will be owned by Source Skincare, LLC, but I can request a copy of them if I wish when they are taken. I am aware that my photos may be edited or made into videos. I am aware that my photos/videos will not be sold to anyone and will stay property of Source Skincare, LLC.
Yes, I consentNo, I do not wish to consent
Signature*
Should be Empty: