New Facial Client

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Would you like to be added to my email newsletter?

Yes please.No thanks.
Phone:*
ex. 555-555-5555
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
How did you hear about me?

InstagramFacebookGoogleOther
Please list any allergies you may have. *

NONEOther
Please list any allergies you may have or type NONE. *
Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?

NOYES
If yes, please list reason:
Have you had skin cancer?*

NOYES
If yes, please list area(s):
Do you have any permanent cosmetics or tattoos on the areas being treated?*

NOYES
If you have had fillers, neurotoxin (botox etc.) or laser hair removal I suggest waiting two weeks before a facial. If you have had PDO thread the wait time is 60-90 days. Please consult with your injector or threading provider.

I understand
Have you had any of these health conditions in the past or present?

CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsyFever blistersHepatitisHerpesCold soresImmune disordersHIV/AIDSLupusMetal implantsPhlebitisBlood clotsInsomniaSeizure disorderKeloid scarringMigranesSkin diseaseActive Infection
Do you follow a regular exercise program?*

NOYES
Do you smoke or chew tobacco products everyday?*

NOYES
Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment.
Do you follow a restricted diet?*

NOYES
What is your current level of stress?

LowModerateHigh
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
Do you currently use any of the following?

Retin-ARenovaAdapaleneDifferinGlycolic AcidAHARetinolAccutaneTazoracRoAccutaneScrubs or PeelsAt home laser
I understand that I must discontinue use of ALL of the above 5 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.*

YES, I will discontinue.
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?*

NOYES
If yes, please explain:
Do you use bleaching creams or Hydroquinone daily?*

NOYES
Do you wear sunscreen?

YESNOSOMETIMES
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

NOHyper-pigmentHypo-pigment
Have you used an acne medication? *

NOYES
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past?*

NOYES
Please explain the details:
Have you ever had an ALLERGIC reaction to any of the following?

AHA'sRetinoidCosmeticsMedicineFoodAnimals / InsectsSunscreensIodinePollenFragranceShellfishLatexTopical RXNONE
Female Clients
Are you pregnant or trying to become pregnant?

NOYES
Do you have Mirena IUD, Copper IUD or other implanted birth control?

NOYES
Are you taking oral birth control?

NOYES
If yes, please explain:
Skin Care History
When washing my face:*

I use hot waterI use warm waterI use cool or cold water
How often do you use a skin regimen?*

1x per day2x per dayI do not use a regimen
Do you feel claustrophobic during facials?*

YESNO
What conditions would you like to improve?*

AcneOily SkinDry SkinBumpsLarge PoresMelasmaRednessBrown SpotsSun DamageMiliaSagging SkinRosaceaLines & WrinklesHealthy AgingWhite spotsScarringAge ManagementKeratosis PilarisHyperpigmentationHypopigmentation
List any additional conditions you would like treated:
Did someone refer you?
Let me know who so I can thank them.
Preparing for your appointment
Current skin care products you use at home. Include brand names and product names if possible.
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 am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Paz Amor Studio and/or the skin care professional from liability and assume full responsibility thereof.*

I understand the cancellation policy.
A credit card will be needed to secure your appointment. A 50% deposit will be requested at the time of booking and goes toward your treatment. This is non refundable. Please cancel or reschedule 24 hours prior to your appointment start time. If you need to reschedule, your deposit will carry over one time and you must book within 7 days. To cancel an appointment please contact Paz Amor Studio at least 24 hours prior to your appointment. If you are running late, you agree to communicate via text. You will still be required to pay the full price of the service and you may only receive the remaining time available. Please understand that there may be a client scheduled after you. 15 minutes late is considered a no show.*

I understand the cancellation policy.
OPTIONAL: I grant permission to Paz Amor Studio to use photos of my treatment for marketing purposes on www.Pazamorstudio.com or other business listing pages such as Instagram or Facebook.

I grant permission.No thank you.
Date*

MonthDayYear
Signature*
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Medical & Skin History