New Client Form

New Client Form

Health & History
Name*

First NameLast Name
Pronouns?
Date of Birth

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email Address
example@example.com
How do you take care of your skin at home?*
YesNo
What are your skin care concerns?*
What are your skin care goals?
What is the primary reason you are getting facials? (i.e. relaxation, self-care, better skincare)*
NormalDryCombinationOilySensitiveAcne Prone
YesNo
YesNo
RashPeelingIrritationSun SensitivityNone of the above
YesNo
ShellfishIodineSulfurGlutenSoyDairyTree nutsPeanutsWheatEggsSeasonalLatexAHA'sFragrancesAspirinNoneOther
YesNo
YesNo
Have you ever had an adverse reaction to a skin care product or facial treatment? If yes, please explain.*
CancerHypertensionDiabetesClaustrophobiaHeart ConditionThyroid DisorderArthritisEpilepsy or SeizuresHIV/AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyBruise EasilyLupusPCOSEndometriosisBlood Clot DisorderActive InfectionFibromyalgiaCold SoresPOTSEDSNoneOther
YesNo
YesNo
YesNo
YesNoN/A
YesNoN/A
YesNoN/A
YesNo
YesNo
YesNo
YesNoN/A
YesNo
EczemaPsoriasisAcneRosaceaNoneOther
YesNo
YesNo
YesNo
YesNo
Peaceful PianoStringsDreamy Forest MusicRain SoundsTranquil SoundscapesChill Coffeehouse
AnxietyADD/ADHDBladder conditionsNone of the above
How may I accommodate you during your service?
I give Afterglow Aesthetics permission to take pictures and videos, and use them on social media or for advertising*
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

MonthDayYear
Date
Should be Empty:

New Client Form

Terms & Conditions