Facial Client Form

New Client's Name

First NameLast Name
Which location are you seeing Carol at?

Los AngelesSan Luis Obispo
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Do you have any of the following conditions? If yes, please select them:

CancerDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CPsoriasisRosaceaEczemaBruise EasilyOpen sores/cuts/rashes/blistersDo you currently have a cold soreAny other medical issue that I should know about? Please discuss with Carol prior to facial.
Are you pregnant?

YesNo
Are you taking any contraceptive pills?

YesNo
Are you breastfeeding?

YesNo
Are you wearing any contact lenses?

YesNo
Are you taking any medications for acne?
Are you taking any supplements or herbs? Please list what they are and doses daily.
Terms & Conditions
I understand that my information will be strictly confidential. This spa does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that if I withhold some important information and complications occured, Carol Dobson Zubrin, Purity Organic Spa / Facials will not be liable.

I release this spa and hold it harmless against any claims, expenses, damages, and liabilities.
Client Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Should be Empty:

Terms & Conditions