• New Client Form

    Health & History
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Do you use SPF?*
  • Please select your skin type(s)*
  • Do you experience breakouts?*
  • Do you experience burning or itching?*
  • Please select any negative reactions you may experience:*
  • Do you experience shine or oil during the day?*
  • Please select any allergies you have:*
  • Have you been on antibiotics recently?*
  • Are taking blood thinners?*
  • Are you diagnosed with any of the following conditions? Select all that apply:*
  • Have you ever had skin cancer?*
  • Do you consume alcohol?*
  • Do you smoke or vape tobacco?*
  • Are you pregnant?*
  • Are you trying or planning to be pregnant?
  • Are you taking any contraceptive pills?
  • Are you or have you done IVF
  • Do you consume caffeinated drinks?*
  • Will you be wearing any contact lenses?*
  • Are you breastfeeding?
  • Do you have any neck, back or shoulder injuries?*
  • Are you under the care of a physician for any of the following?*
  • Have you had a chemical peel, laser, dermaplaning, microcurrent, microneedling, microdermabrasion/hydrodermabrasion treatment, or LED treatment in the past 6 months?*
  • Have you taken Accutane or used Retin-A/Renova within the last 12 months?*
  • Do you tan regularly?*
  • Do you have a pacemaker, port, dental implants, body piercings, or pins in bones?*
  • Do you struggle with any of the following? Please check all that apply.*
  • What type of music appeals to you?*
  • What's your vibe?*

  • Terms & Conditions

  • I understand that all information I've provided is strictly confidential. Afterglow Aesthetics never sells or shares any data that I provide.

    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/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive at Afterglow Aesthetics are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

  • Date Submitted
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