luent untake form

Skin A Peel Beauty Lounge

New client Intake Form
Name*
Date*

MonthDayYear
Date
Age*
Date of birth*

MonthDayYear
Date
Address*
City*
Postal Code*
Email Address*
Phone*
Emergency Contact*
Medical History
Please mark any of the following that apply*

AcneAutoimmune disordersCold sores or fever blistersCOPDCancerDiabetesDermatitisEczemaEpilepsyGlaucomaHeart DiseaseHigh Blood PressureHepatitis B or CHerpes SimplexHemophiliaHIV/AIDSKeloids or hypertrophic scarsMigrainesPsoriasisRosaceaSkin infectionsSeborrheicTineaHivesWartsN/AOther
HEALTH UESTIONNAIRE
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
Have you ever experienced claustrophobia?*
FEMALE CLIENTS

Please answer yes or no to the following questions below, please specify if answer is yes
Are you pregnant or trying to become pregnant?
Are you undergoing any hormone replacement therapy?
Are you taking birth control
I understand have read and completed this questionnaire truthfully I agree that this constitutes full disclosure. and that itsupersedes any previous verbul 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 1 release this skin care professional from liability and assume full responsibility thereof.
Client Printed Name*
Clients Signature*

Clear
Date*

MonthDayYear
Date
Estheticain Name
Esthetician Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Skin A Peel Beauty Lounge

Medical History

HEALTH UESTIONNAIRE

FEMALE CLIENTS