SKIN BY PATTY | Skin Client Consultation Form

SKIN CONSULTATION FORM

Only fill out if you have an appointment coming up & it’s your first time ♡
Client's Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ethnicity *
AcneArthritisAsthmaBlood disorderCancerDiabetesEczemaEpilepsyFever blistersHeart conditionKeloid scarringHepatitisHigh blood pressureHIV/AIDSHyper pigmentationHypo pigmentationHysterectomyImmune disorders InsomniaLow blood pressure LupusMetal bone pins/platesPhlebitis, blood clotsSeizure disorderSkin disease/lesions SeborrheaThyroid conditionVaricose veinsWartsNoneOther
NormalOilyAcneDryCombinationRosaceaSensitiveOther
FastPigmentsScarsSlowOther
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, what are your allergies ?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
What are your skin concerns and skin goals, write down please :)*
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
How did you hear about SKIN BY PATTY LV ? *
Thanks 🤍
Can I take pictures/videos ? *
Terms & Conditions
By signing below, you agree to the following:

I am over 18 years of age and consent to the agreement and to treatment or have a parent with me that consents to this service.

I have completed this form truthfully and to the best of my knowledge.

I agree to inform the technician of any changes in the above information.

I agree that I do not have any condition/s that would make the requested treatment unsuitable.

I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health.
Client Signature*

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Date Signed*

MonthDayYear
Date
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SKIN CONSULTATION FORM

Terms & Conditions