Urban Esthetics

Full Name

First NameLast Name

Date of Birth

Phone Number

Format: (000) 000-0000.

Email Address

example@example.com

Check the conditions that apply to you or any member of your immediate relatives:

Please Select your primary skin concern?

Do you use birth control pills, shot or IUD??

YesNo

If so, which kind?

Are you pregnant or nursing?

YesNoNot Sure

Please list any allergies:

What kind of drugs? How long have you used/been using them?

Please list your At home Skincare Regiment?

Rows	Please List Products
Cleanser
Toner
Serums
Moisturizer
Sunscreen
Masks
Other

Do you see a Dermatologist?

YesNo

Do you use tanning beds/ tan in the sun?

YesNo

Do you prefer a "silent appointment"?

YesNo

Do you consent to photos/videos being taken and shares?

YesNo

Policies
No-Show / Cancellations
You will receive multiple reminders for your appointments prior to the scheduled day. Urban Esthetics asks that you cancel or reschedule your appointment at least 24 hours in advance. If you do not cancel or reschedule within this time frame, you will be charged 50% of the service fee. Once the fee is paid, you will be able to reschedule your appointment.

Late Arrivals
Urban Esthetics allows a 15-minute grace period for late arrivals. Clients arriving later than 15 minutes risk having their appointment shortened but will still be charged for the full service.

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