Client Update Form

CLIENT UPDATE FORM
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Do you:*

Wear contact lensesHave a pacemakerHave metal implantsWear hearing aidsNone of the above
Have you been under the care of a dermatologist in the past year? If yes, please explain:*
Do you have any allergies to any food, skin care ingredient or medication? If yes, please specify:*
Are you currently on any medication? If yes, please specify:*
What are your current concerns about your skin?*

Lines/WrinklesPigmentationAcneRedness/SensitivityDullnessDrynessPore SizeScarringTextureOilinessOther
Your skin care routine at home includes:*

CleanserExfoliantTonerSerumMoisturizerMaskEyecreamSPFRetinolAHA (Glycolic Acid, Lactic Acid ...)BHA (Salicylic Acid)HydroquinoneRetin AOther
Have you ever been prescribed Accutane? If yes, for how long and when was your last date used?*
Have you recently or currently received any of the following treatment?*

Chemical PeelMicrodermabrasionLaser/IPLMicroneedlingChemotherapyOther
Have you received Botox, Restylane or any type of injections on your face in the last 6 months? If YES, please specify:*
Any additional information you would like to inform your esthetician:
Cancellation Policy:

If your need to reschedule or cancel your appointment, we respectfully request 24 hour notice. Cancellations or rescheduling without 24-hour notice or no-shows will result in a 50% charge of the total service amount to your credit card.

Late Arrival Policy:

If you are late for your appointment, we will try our best to accommodate. However, please keep in mind that your service time may be shortened in order for us to be on time for the next client. You will still be responsible for the full amount of your services including the services which we did not have enough time for.
I have completed this form to the best of my knowledge and agree to inform the esthetician of any changes with the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable.

I agree to waive all liabilities toward my esthetician for anyar injury or damages incurred due to any misrepresentation of my health history.

I agree to the cancellation/late arrival policies and charges associated.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

CLIENT UPDATE FORM