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
Which of the following best describes your skin type? (Please Check One)
Are you currently under the care of a physician? Yes or No If Yes, Who?
Do you have the following medical conditions? (Please Check all that Apply)
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
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced)

Other
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?
Do you consume Alcohol?
Have you ever had laser hair removal?
Have you used any of the following hair removal methods in the past six weeks?
Have you had any recent tanning or sun exposure that changed the color of your skin?
Have you recently used any self-tanning lotions or treatments?
Do you form thick or raised scars from cuts or burns?
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma? If yes describe below.
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 :
Are you pregnant or trying to become pregnant?
Are you currently breastfeeding?
Are you using contraception?
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.
Do you agree with the statement above?
Signature
Should be Empty: