Client Form

Date

Name*

First NameLast Name

Gender

FemaleMale

Date of Birth*

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Referred By:

Occupation*

Does your job require you to work outdoors?

YesNo

Are you currently taking any medications?*

Do you have any of the following conditions? If yes, please select them:

Do you consume alcohol?

YesNo

Do you consume caffeinated drinks?

YesNo

Are you wearing any contact lenses?

YesNo

Are you currently under any kind of diet?

YesNo

Have you undergo any surgeries?

YesNo

Your Skin
Please answer all questions honestly for best results from your appointment!

Have you had a facial before? If so when?*

Which of the following best describes your skin type?*

Skin condition

How does your skin heal?

Do you have any special skin problems or concerns pertaining to your face or body?*

Do you use Retin-A, Renova, Accutane, Adapalene Hydroxyl Acid or Retnoil/Vitamin A Dervived Products? Have you used them within the past 3 months?*

Are you taking any medications that is related to cosmetic or skin improvement? (Acne Medications)*

Have you had any Botox, Resatylane or Collagen Injections? If so when?*

What Skin Care products are you currently using? (List brand where known)*

Have you used any of the following hair removal methods in the past 6 weeks? Click all that apply

What areas of concern do you have regarding your skin? (Please click all that apply)*

Please Explain:

Eyes:

DehydratedWrinklesPuffinessDark Circles

Lips:

DehydratedCracked or ChappedOther

Are you Allergic/ Sensitive to any products ingredients?*

What sunscreen do you use on your face?

Are photos/videos taken during service for promotional purposes during your service okay?

YesNo

What would you like to achieve from your service today?*

Female Clients Only:

Are you pregnant or trying to be?

YesNo

Are you breastfeeding?

YesNo

Are you taking any contraceptive pills?

YesNo

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.

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

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect.

I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved.

I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.

I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.

I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ-ous 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 institution and/or skin care profes- sional from liability and assume full responsibility thereof.

If I experience any pain or discomfort during the session> I will immediately inform the esthetician so that the products and/ or technique may be adjusted to my level of comfort. I further understand that the service being performed should not be constructed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe or treat any physical or mental illness, and that nothing said in the course of the session given should be sonstrueded as such. Because certain treatments should not be performed under medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session> I also understand that the Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom she deems to have a condition for which treatments are contraindicated.

Client Signature

Date Signed

Date

Client Form

Terms & Conditions