Form

Client’s Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Date of birth

Date

Gender

Do you prefer:

What type of music inspires you?

What’s you drink of choice?

What’s your choice of essential oil?

How would you describe your current skin type?

How often do you currently receive professional skincare treatments?

Have you had direct exposure to the sun or tanning bed treatments in the last 48 hrs?

Do you burn easily?

How does your Skin Heal ?

Have or are you currently using any type of Medication prescribed by a Dermatologist? (TRETINION, ACUTANE/RETINA A, ETC) If yes, Please Advise

Are you currently using any products that contain the following ingredients? (Glycolic acid, Lactic Acid, Salicylic, Benzoyl Peroxide, Exfoliating Scrubs, Hydroxy Acid, Vitamin C, Vitamin A Derivatives, Retinol) If yes, Please Advise

What are your top 1-2 skincare goals or concerns?

Do you have any known allergies? (e.g., nuts, latex, aspirin, fruit, specific skincare ingredients)

If yes, Please list allergies below

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

Are you pregnant or planning to be

Are you Breastfeeding?

Have you undergone any surgeries?

If Yes, Please Advise.

Are you taking any medications?

If Yes, Please Advise.

Terms & Conditions

I have cited all conditions and circumstances regarding my health history: Including medications being taken, and any past reactions to products or medications that could prohibit or compromise this treatment.

I understand that additional conditions could occur which could affect my ability to tolerate the TREATMENT: I further understand there are risks associated. In rare cases, eye/skin irritation and discomfort may occur. I further understand there are risks associated facial treatments. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I fail to use a minimal SPF sunscreen (SPF45), I am more susceptible to sunburn, skin damage and hyper pigmentation: I further understand that I should avoid excessive sun exposure.

I understand that aftercare needs to be followed: I understand that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home and aftercare regimen for 2-4 weeks following treatment.

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

Signature

Date Signed

Date

PERSONAL INFORMATION:

PREFERENCES:

SKIN INFORMATION:

HEALTH HISTORY