PerfectSkin Aestheticstt
BODY CONSULTATION FORM START YOUR JOURNEY TO GLOWING SKIN
Client's Information
Client Personal Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Medical history
Do you have an active lifestyle?
Yes
No
Have you ever visited a Dermatologists for you skin issues
Yes
NO
Are you on any prescribed medication
Yes
No
If yes, please list below
Are you aware of any allergies you may have?
Yes
No
If yes, please list
Please Select
Rashes
Itches
Burning
Swelling
Redness
Bumps
Hives
Do you experience any of the following symptoms
Redness/Burning
Hives/rashes
Swelling/itching
Dryness/Flaking
Are you on any specific diet?
Yes
No
If yes, please indicate
Have you been diagnosed with a autoimmune disease/disorder by an physician
No
Yes
If yes, please list the type
Treatment History
Client Treatment history
Have you ever done any professional treatment/peels/body microdermabrasion on your body?
Yes
No
If yes, please state when was your last treatment and what treatment you have done.
What are your main concerns and what skin issues you will like to improve?
Body discoloration
Body Acne
Stretch Marks
Skin tags/moles
How long have you been experiencing this skin issue?
Do you wear sunscreen?
Yes
No
Please indicate if you have ever use the any of the following active ingredients on your skin
Retin A
Kojic acid
Hydroquinone
Azelaic acid
Glycolic acid
Lactic acid
Do you give permission to Medical Aesthetician Venessa Gordon of PerfectSkin Aestheticstt to offer body treatments to you?
Yes
No
Signature
Submit
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