New Client Registration Form

New Client Consultation:
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
Birthday

MonthDayYear
Date
Referred by
Have you ever had a facial treatment before? When was the last one?
Do you have any special skin problems or concerns pertaining to your face or body?
Specify, if you answered Yes
Emergency contact / phone number

Which of the following best describes your skin type? (circle just one)
Have you ever had chemical peels, laser or microdermabrasion? When was the last treatment?
Specify When, if you answer Yes
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, or Retinol (Vitamin A) derivative products?
Have you used any of these products in the last 3 months?
Have you experienced Botox, Restylane or Collagen injections? When was the last treatment?
Specify when
Have you used an acne medication? When? Which drug?
Have you recently used any self-tanning lotions, creams or treatments?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
What skin care products are you currently using? List brand if known
Do you form thick or raised scars from cuts or burns?
Do You have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
List your daily consumption of:

Future Appointments / Contact
May I call/text your cell/home number to confirm future appointments?
May I contact you via mail/email about future promotions and news?
I understand, have read and complete this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes 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. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 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 this history.
Signature
Today’s Date
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New Client Consultation: