MEDICAL HISTORY + CONSENT FORM
Ruby Williams Aesthetics
Client Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Shipping 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
Please take a moment to answer the following questions
Are you currently taking any medications?
*
Yes
No
Please list
*
Please check if you are affected by or have any of the following
*
Anemia
Neurological Disorders
Diabetes
Hemophilia
Cancer
High Blood Pressure
HIV/AIDS
Pace Maker
Herpes Simplex (Cold Sores)
Heart Disease
Psoriasis
Skin Disease
Staph Infection
Lupus
Eczema
Keloid Scarring
Cancer
Metal Implants
Rosacea
Bruise Easily
Migraines/Headaches
Epilepsy or Seizures
Gut Imbalances
Blood Clot Disporder
Hormone Disorder
None
Do you have any allergies to cosmetics, food, or drug?
*
Have you ever had an adverse reaction from a product or treatment on your face? If yes, please explain:
*
Are you pregnant, nursing, or trying to conceive?
*
Do you use birth control pills, shot, or IUD? If so, which kind?
*
What skin care products do you currently use?
*
Cleanser
Toner
Antioxidant Serum
Eye Cream
Spot Treatment
Moisturizer
Sunscreen
Vitamin C Serum
Face Oil
Retinol/AHAs/BHAs
Other
Please list skincare products you reach for daily (include brand if possible)
*
Do you wear sunscreen?
*
Every single day
Only in the summertime
When I remeber
Never
What are your current skin concerns?
*
Rows
Please select
Acne
Aging
Texture
Pigmentation
Pore Size
Scarring
Sunburn
Elasticity
Rosacea
Eczema
Not Sure
What would you say your overall skin type is?
*
Rows
Please select
Normal
Dry
Mature
Combination (oily T-zone + Dry everywhere else)
Oily
Not Sure
Please list any other skincare goals or concerns that you may have.
Have you used Retin-A, Renova, Adapa-lene, Accutane, Differen, or acids (AHAs or BHAs), or Dermatologist prescribed topicals within the last week? Please specify
*
Are you open to adjusting your skincare routine if it will improve your results?
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Not at the moment
Maybe a few products
Yes, if recommended
Absolutely! I want the best routine possible
Are you wanting RUBY WILLIAMS AESTHETICS to customize a treatment plan designed to achieve your goals?
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Yes, I prefer a structured plan
Possibly open to it
Not a fit for me right now
What is your goal in working with an Aesthetician?
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Regular in-office treatments
Receive and follow an esthetician guided homecare routine
Both
Have you received botox or filler within the last two weeks
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Yes
No
Do you see a dermatologist?
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Yes
No
Do you prefer a silent appointment?
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Yes
No
No Preference
Are you okay with photos/videos being posted of your service?
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Yes
No
Yes, but block out eyes
What inspired you to seek professional skincare treatments at this time?
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I have a specific event I want my skin looking its best for!
I've tried many things and want professional guidance.
I simply want to maintain healthy skin!
I'm finally wanting to commit to improving my skin long term!
Other
How did you hear about RUBY WILLIAMS AESTHETICS?
*
Terms & Conditions
I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my skin care specialist will take every precaution to minimize or eliminate negative reactions as much as possible. By signing this I hold my skin care specialist harmless and nameless from any liability that may result from this treatment.
*
I understand and agree to the terms and conditions
POLICIES **PLEASE READ**
By agreeing to our policies, you understand that this appointment at RUBY WILLIAMS AESTHETICS is reserved exclusively for you and requires a 24-hour notice for cancellation or rescheduling. Canceled or rescheduled appointments within 24 hours will incur a 50% cancellation/No-show fee will be charged.
By submitting this form, you acknowledge and agree that this document serves as proof of your consent and participation. Any attempt to dispute the transaction will be met with this evidence, confirming that you have willingly filled out and agreed to the terms stated.
*
I understand and agree to the cancellation policies
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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