Client Consultation/Health Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Gender
*
Female
Male
Other
How were you referred to Pretty Wild Salon?
*
Occupation
*
Does your job require that you work outdoors?
*
Yes
No
What would you like to achieve from your treatment today?
*
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Your Skin Care
Massage of Choice (please choose 2)
*
Neck and Shoulder
Hand and Arm
Foot Massage
Scalp Massage
Have you ever received a facial treatment before?
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Yes
No
Have you ever received a body treatment before?
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Yes
No
If yes, please specify when and what treatment
Which of the following best describe your skin type? (please check one)
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Type 1- Fair skin tones-- Always burns, never tans
Type 2- Light skin tones-- Burns easily, tans slightly
Type 3- Fair to olive skin tones-- Burns moderately, tans moderately
Type 4- Light brown skin tones-- Burns slightly, tans easily
Type 5- Dark brown skin tones-- Rarely burns, tans easily
Type 5- Dark brown to black skin tones- Never Burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?
*
Yes
No
If yes, please specify
Have you ever had chemical peels, laser treatments, or microdermabrasion to your face or body?
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Yes
No
In the last month?
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Yes
No
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/ Vitamin a derivative products?
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Yes
No
If yes, please specify what and when last used
Have you used any acne medications?
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Yes
No
If yes, please specify what and when last used
What skin care products are you currently using?
*
Cleanser
Toner
Serum(s)
Day Moisturizer
Night Moisturizer
Exfoliatior
Mask
Eye Products
SPF/Sunscreen
Other
Have you used any hair removal methods in the past 6 weeks? If Yes check all that apply
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Yes
No
Shaving
Waxing
Electrolysis
Plucking/Tweezing
Stringing
Depilatories
Other
What Areas of concern do you have regarding your: Skin
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Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Redness/ruddiness
Blackheads/whiteheads
Broken Capillaries
Dehydrated
None
Other
What Areas of concern do you have regarding your: Eyes
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Puffiness
Wrinkles
Dark Circles
Dehydrated
None
Other
What Areas of concern do you have regarding your: Lips
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Cracked/chapped lips
Dehydrated
None
Other
What SPF do you use on your face? How often?
*
Have you used any self tanning lotions, creams, or treatments?
*
Yes
No
If yes, please specify
Have you had any recent tanning bed or sun exposure that canned the color of your skin?
*
Yes
No
If yes, please specify
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Health History
Have you been under the care of a physician, dermatologist, or other medical professional within the past year?
*
Yes
No
If yes, please explain
Any recent surgery, including plastic surgery?
*
Yes
No
If yes, please explain
Any skin cancer?
*
Yes
No
If yes, please explain
Have you had an allergic reaction to any of the following?
*
Cosmetics
Fragrance
Animals
Drugs
AHAs
Iodine
Medication
Shellfish
Pollen
Egg
Gluten
Nuts
Soy bean
Cocoa
Papaya
None
Other
Have you had any of these health conditions in the past or present?
*
Cancer
Hormone imbalance
Systematic disease
High blood pressure
Thyroid condtion
Hysterectomy
Diabetes
Heart problem
Varicose veins
Arthritis
Asthma
Eczema
Epilepsy/seizure disorder
Fever Blisters
Headaches (chronic)
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Blood clotting abnormalities
Psychological treatment
Insomina
Keloid scarring
Skin disease/skin lesions
Any active infections
None
Other
How many glasses of water do you drink per day?
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1 glass
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc...) do you consume per day?
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None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week?
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I don't drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours of sleep do you get per night?
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3 hours
3-5 hours
6-8 hours
10+ hours
which food do you consume on a regular basis?
*
Fruits
Fish
Vegetables
Grains/Breads
Diary/Eggs
Processed Sugar
Cheese
Meats
Chicken
Other
What Does your daily commute look like?
*
Bike
Car
Public Transport
I don't commute
Other
How often do you travel on a plane?
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Never
1-2 times per year
1-2 times per quarter
Every month
Every week
How many hours do spend in front of a screen or digital device?
*
3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?
*
Yes
No
Do you smoke cigarettes, vapes, or consume other tobacco products?
*
Yes
No
What is your stress level on a scale from 1-5
*
Low Stres
1
2
3
4
High Stress
5
1 is Low Stres, 5 is High Stress
Do you follow a restricted diet?
*
Yes
No
If yes, please explain
Please list any medications you take on a regular basis
*
Do you form thick or raised scars from cuts or burns?
*
Yes
No
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
*
Yes
No
If yes, please explain
Do you wear contact lenses?
*
Yes
No
Are you claustrophobic?
*
Yes
No
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Female Clients only
Are you taking any oral contraceptives
Yes
No
If yes, please explain
Any recent changes to or from your contraceptive treatment?
Yes
No
If yes, please explain
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
Any menopause problems?
Yes
No
If yes, please explain
Please use this space to complete answers where space was insufficient. please state which question. as well as any other information can be added here as well.
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I understand, have read and completed this questioner truthfully I agree that this constitutes full disclosure, and that it suspended 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 history. The treatments I receive here are voluntary and I relate the institution and/or skin care professional from liability and assume full responsibility thereof.
May I call you at the provided phone number to confirm future appointments?
*
Yes
No
May I contact you at the provided email about future promotions and news?
*
Yes
No
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Consent Form
Name
First Name
Last Name
Information
Although every precaution will be taken to ensure your safety and well being before, during, and after your treatment/procedure. Please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please inital:
I hereby consent to and authorize the technician/esthetician to preform the treatment/procedures
*
I Voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved
*
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications
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I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
*
I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
*
I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
*
Photo Release
*
I give permission for my hair to be photographed and used for marketing/social media
I do NOT give permission
Information
I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today.
Please Sign
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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