Skin Glow New Client Paperwork

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

Today's Date*

Date

Name*

Age*

Phone*

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Who can we thank for referring you?*

What is the main concern with your skin?*

How would you describe your skin?*

Which of the following would you like to improve?*

How would you rate your skin?*

I Always Burns, never tansII Always Burns easily, tans slightlyIII Burns Moderately, tans graduallyIV Seldom burns, always tansV Rarely burns, deep tansVI Never burns, deeply pigmented

Have you ever had?*

Do you currently tan outside or use a tanning bed?*

What is your current Skincare Regimen?*

Please list the current namebrand and name of your cleanser, toner, moisturizer, exfoliator, SPF.

Have you every used any skincare products that caused a reaction?*

If so, please list what product and reaction that occurred

Are you allergic/sensitive to:*

Do you have any other allergies?*

Please list any allergies to ingredients not listed above

Do you currently use depilatories, sugar or wax? If so, last time used?*

How does your skin heal?*

FastSlowScarringPigmentation

What medications are you currently taking? Please indicate what kind of medication it is (ex: steroid, antibiotic, birth control) (High percentages of certain ingredients may increase skin sensitivity)*

Please list name of medication and what it is prescribed to treat

Have you had any of the following (past or present)?*

Have you ever used?*

Women, please check below:*

Do you use birth control?Are you pregnant?Are you lactating?N/A

Do you regularly exercise?

Do you have food intolerances? What?*

Do you follow any special diet?*

How many glasses of water do you consume daily?*

How many cups of caffeine type beverage (coffee. tea, soft drinks) do you consume daily?*

I, {name} do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care therapist will inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary.

I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures so that I may obtain maximum effectiveness.

Our goal is to partner with you to help you achieve your skincare goals so your skincare therapist will recommend the appropriate schedule for future facial treatments and daily care home products. 80% of success depends on you doing your part at home.

In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional Misty Kasic, Skin Glow, LLC and the staff harmless from any liability for adverse reactions that may result from this treatment, future treatments and daily home care products used.

{signature}{todaysDate}

POLICIES:

1. For safety purposes, children are not permitted in studio. Please do not bring additional guests to accompany your appointment; only one guest is permitted within our studio at a time.

2. Chemical peels will not be performed on first time clients. Daily pre home care products are required for least 2-4 weeks prior to receiving a chemical peel and daily post home care are required 5-7 days after to minimize any adverse effects. Daily homecare instructions will be discussed in your consultation appointment. Chemical peels offer best results in a series of 4-6 sessions.

3. As an independent skincare owner, prices reflect the fair value of Misty Kasic's expertise, advanced education, experience & time. Therefore, Skin Glow does not accept gratuities. In lieu of gratuities, Skin Glow accepts and is grateful for the following:

Your referrals! Nothing would honor Skin Glow more :)
Your endorsement via online review on Google or Yelp is appreciated!

4. Our time together is valuable in succeeding in your skincare goals! We do ask that you arrive 15 minutes prior toyour scheduled appointment for new clients to ensure you have time to fill out new paperwork. We do ask that you arrive 5 minutes prior to your scheduled appointment for follow ups to receive the full treatment. While Skin Glow is not a spa, you may request a silent appointment.

5. If you are experiencing any illness or cold sores on the day of your appointment, we cannot provide service and will need to reschedule you. If you are late to your appointment your service will be shortened by that amount of time. Please provide 24 hours notice for cancellation/rescheduling to avoid 50% fee of the service amount.

6. If your skincare therapist feels that you are not participating to the best of your ability or using other products that are not recommended during your treatment(s), she may terminate future appointments and release you as a client.

I have read and agree to Skin Glow's terms and policies as outlined above.*

Signature*

Date*

Date