HiddenUntitled CLIENT NAME: GENDER: M F OTHER DOB MM slash DD slash YYYY ADDRESS: Address ADDRESS CITY State ZIP PREFERRED CONTACT NUMBER:Email May we leave a message if we do not reach you personally? No Yes WHAT ARE YOUR TOP 3 SKINCARE CONCERNS: First: Second: Third: MEDICAL HISTORY:Pregnant? No Yes Breastfeeding? No Yes Do you smoke? No Yes Health Conditions: Past Surgeries: Have you ever been diagnosed with Cancer? No Yes (last treatment date) MM slash DD slash YYYY Current Medications: Prescription Topicals: Allergies (include aspirin & iodine): PREVIOUS TREATMENTS:Facials No Yes Last treatment: Any complications? Dermabrasion No Yes Last treatment: Any complications? Chemical Peels No Yes Last treatment: Any complications? Injectables No Yes Last treatment: Any complications? Waxing No Yes Last treatment: Any complications? Tanning No Yes Last treatment: Any complications? Laser Therapy No Yes Last treatment: Any complications? Light Therapy No Yes Last treatment: Any complications? Microcurrent No Yes Last treatment: Any complications? Massage No Yes Last treatment: Any complications? SKIN CONDITIONS: Skin Infection Skin Cancer Eczema Sun Sensitivity Herpes (cold sores) Poor Healing Psoriasis Easy Bruising Keloids/Excessive Scarring Tattoos/Permanent Makeup Lymph Nodes Removed Auto Immune Condition (please check all the items below that pertain to you)SKINCARE:What type of skin do you feel you have? Dry Oily Normal Combination What is your skin routine?(Indicate any cleansers, toners, serums, moisturizers, masques, etc.) 1. 2. 3. 4. 5. 6. CLIENT NAME: Date MM slash DD slash YYYY PLEASE INITIAL:PLEASE INITIAL: I agree that the nature and purpose of the treatment has been explained to me, and any questions I have regarding the treatment have been explained to my satisfaction. I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur. I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days. I do not have active cold sores. I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur. I understand that it is recommended prior to having a facial infusion to not have used Retin A for 48 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment. SignaturePRINT NAME Date MM slash DD slash YYYY
