New Client Paperwork
This is to be filled out by all new clients. If you are a returning customer, you don't need to fill this out unless there has been a change to medications, skin care routine, and conditions. Failure to update your form may result in complications from the treatment including but not limited irritant reactions, chemical burns, and more.
Contact Information
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
General Questions
Have you ever received a skin care treatment?
Yes
No
What areas of concern do you have? Please check all that apply
Fine Lines/Wrinkles
Excess oil/acne
Dark areas/hyperpigmentation
Dry or Irritated Skin
Signs of Age
Other
Do you currently use any of the following?
Cleanser
Toner
Exfoliant/Facial Scrubs
Masks
Serums
Eye Cream
Sunscreen
Moisturizer
Are you currently receiving any of the below treatments
Cosmetic Surgery
Cosmetic Fillers
Cosmetic Injections
Chemical Peels
Microdermabrasion
Retin A
Laser Hair Removal
Have you ever had a negative reaction to the following?
Fragrances
Medications
Cosmetics
Food
Other
Do you wear contact lenses?
Yes
No
Are you currently pregnant?
Yes
No
Are you taking birth control?
Yes
No
Do you smoke?
Yes
No
Do you have any food intolerances?
Do you have any of the following health conditions?
Acne
Allergies
Arthritis/Bursitis
Cancer
Diabetes
Eczema
Claustrophobia
Epilepsy
Headaches
Helpatitis
Infections
HIV/AIDS
Lupus
Pacemaker
Metal Implants
Psoriasis
Vitiligo
Serious Injury
Thyroid Issues
Phlebitis
Hypertension
Heart Problems
Autoimmune
Disease
Other
Please list any current medications, hormone replacements, and/or vitamins/supplements you are taking:
What would you rate your stress level as?
Low
Medium
High
How many glasses of water do you drink on average?
Which statement is true for your skin?
Always burns, never tans
Burns easily, tans slightly
Burns moderately, tans gradually
Rarely burns, always tans well
Never burns, deeply pigmented
Liability Waiver
I understand that the service will be provided by a STUDENT of esthetics and that the student is not yet as proficient, experienced, or trained in all of the techniques a registered facial specialist would be expected to know. I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous 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. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. The treatments I receive here are voluntary and I release this institution and/or practitioner from liability and assume full responsibility thereof. Attached to this form is the contact information for Dakota Wright, owner of QRTZ Skin Spa LLC & student of Health & Style Institute.
Name
First Name
Last Name
Signature
Date Signed
-
Month
-
Day
Year
Date
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