New Acne Client Questionnaire

New Acne Client Questionaire

PLEASE FILL OUT THIS FORM ONLY IF YOU ALREADY HAVE A SCHEDULED APPOINTMENT !
Date

MonthDayYear
Date
Clients Name

First NameLast Name
Email
example@example.com
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Birthdate
Age
How did you hear about Beauty By Gerda Esthetics ?

Please list your current AM/PM skincare routine:
Are you using a daily SPF? If so, what kind?
Have you had any bad reaction to anything you put on your face? If so, please list in detail
Are you allergic to the following?

Other
Please list any known allergies:
At what age did you start having acne?
Do you smoke?
Do you regularly swim in a chlorinated pool?
Do you use fabric softeners, scents or dryer sheets?
Do you work around chemicals, tars or grease?
Occupation:
Do you work nights?
Are you currently under stress? (new job, job loss, wedding, romantic breakup, school, death of a loved one, graduation, difficult home life, long commute, heavily scheduled, new parent, recently moved, medical condition)
Are you a vegetarian or a vegan?
Do you play sports ?
Do you exercise ?
Have you used Accutane (isotretinoin) in the past 6 months?
Women Only: Are you pregnant, trying to become pregnant, or nursing?
Women Only: Are you using a hormonal birth control? If so, please list and for how long:
Men Only: Do you have shaving/ irritation on your face?

Acne Treatment and Consent:

An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 60-90 minutes to complete and are designed to balance, hydrate, clear acne impactions and prepare the skin for home care. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.

Please read and initial the following carefully:
I have not had any chemical peel of any kind 14 days prior to this treatment. I understand that I cannot have any other treatments performed to my face without consulting Beauty By Gerda Esthetics.
Initial
I have not had any facial waxing within 7 days of this treatment. I will not get waxing for 7 days following this treatment.
Initial
I have informed Beauty By Gerda Esthetics of any topical or oral medications I am using, including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac), Accutane, or antibiotics.
Initial
I agreed I have not been exposed to excessive sun or wind and my skin is not irritated in anyway. I understand my skin cannot be compromised to receive treatments.
Initial
I recognize that the products Beauty By Gerda Esthetics recommends are clinical strength active formulas that are designed to treat problematic skin. Tingling sensations are normal with product application but should not be painful. If I experience pain or discomfort, I will contact Beauty By Gerda Esthetics
Initial
I understand I cannot bring my pets or children to my Beauty By Gerda Esthetics appointment. (Message me directly if there's any issues)
Initial
I agree to Beauty By Gerda Esthetics 48 hour rescheduling policy. Beauty By Gerda Esthetics will charge 100% of the service cost for no show appointments. Appointments canceled or rescheduled less than 48 hours of the appointment will be charged %0 fee. I understand that if I'm late, cancel or no show more than two times, I will agree to an updated cancellation policy; if I miss or no show again, I can no longer be a client at Beauty By Gerda Esthetics.
Initial
I agree not to pick at my acne, as it may inhibit my progress and treatments.
Initial
I agree to avoid direct sunlight for at least 2 days following treatment.
Initial
I agree to wear SPF 30 everyday (NONE NEGOTIABLE! INDOORS AND OUTDOORS).
Initial
I understand that controlling acne is best achieved through treatments every two weeks, using homecare as directed, and following all diet and lifestyle recommendations. I understand that without following the suggestions by Beauty By Gerda Esthetics, I may not get my desired results.
Initial
I have informed Beauty By Gerda Esthetics of all health problems that I am aware of.
Initial
I consent to photographs taken of me to be used for monitoring treatment progress and promotional purposes.
Initial
I agree to the above and consent to the treatments performed on me. I agree that I will inform Beauty By Gerda Esthetics of any changes to my skin. I agree to follow homecare and post-treatment instructions.
(Yes or No)
Print Name

First NameLast Name
Name of Parent/ Guardian (if under 18)

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Rows	Currently Using	Previously Used
Antibiotics
Accutane
Benzoyl Peroxide
Retin A (Vitamin A/ Retinol)
Tazorac
Differin
Epiduo
Azelex
Avita
Cleocin-T
E-mycin -T
Copaxone
Corticosteroids
Quinine
Steroids
Marijuana
Cocaine/Speed

Rows	Daily	Weekly	A few times a month	Monthly	Never
Fast Food
Processed Food
Salty Snacks
Milk
Yogurt
Cheese
Other Dairy
Whey or Soy
Peanut Butter
Peanuts
Sushi
Kelp/ Seaweed
Miso Soup
Soy
Seafood
Sugary Foods
Alcohol

New Acne Client Questionaire