Evoke Healing Space - New Client Form

Evoke Healing Space - New Client Form
Name
Phone Number
Please enter a valid phone number.
Date

MonthDayYear
Date
Street Address
City, State, Zip
Birthday

MonthDayYear
Date
E Mail Address
example@example.com
How did you hear about us?
For your safety and well-being we would like you to answer a few health related questions. This information will remain confidential.
What are your goals for your session today?
Any major surgeries?
Surgery Details
Are you pregnant?
# of months pregnant.
Have you had a fever or flu like symptoms in the last 14 days?
Any allergies?
Any Skin conditions?

WartsToenail FungusPsoriasisEczemaAcneDry Scalp
When was your last facial?
When was your last chemical peel?
Have you had Botox or Filler?
If yes, when was your last treatment

MonthDayYear
Date
In the past three months have you used any of the following:

AccutaneRetin -AGlycolic AcidSalicylic AcidAHA or Retinol/ Vitamin A derived products
Please Select All That Apply:

Puffy EyesDark CirclesDehydrationHyper PigmentationAcneRosaceaFine LinesWrinklesSun DamageScarringDrynessOilinessCombinationSensitive SkinCold Sores
What skin care products do you use?
Do you usually break out after skin care treatments?
Is there anything that we should know about you that we have not asked that can help us to better serve you?
I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur. I understand that possible side effects include but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples or allergic reactions.

Most side effects are temporary and dissipate within 3-7 days.

I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.
Client Signature*

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Date*

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Date
Should be Empty: