Updated Client Treatment Record
Professional Treatment Consent Form
Client Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Have you had any changes to the following since we last saw eachother?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health:
Medications:
Skin Care Products:
Hormones:
In the 5 days have you... (select all that apply)
Had any waxing or depilatories on your face?
Had any excess exposure to the sun?
Been in a tanning bed?
Been ill?
Had any surgical/aesthetic procedures?
If yes to any of the above, when?
In the last 24 hours have you...
Exercised?
Used Retin A (or any retinoids)?
Had unusual stress?
What are your plans for the rest of the day?
What are your plans for the next 7 days?
Is there anything else that you'd like me to know?
Signature
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Should be Empty: