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Name:
*
I, the undersigned, recognize the importance of the accuracy of the information provided to facilitate the most effective treatment protocols I will be receiving. Consequently, I confirm this information to be exact.
*
Phone
*
Skin Care Consent Form
Female clients only
Are you pregnant or trying to become pregnant/
Are you lactating?
Are you menopausal?
Date
*
Health History
Presently under care of doctor or dermatologist?
Presently taking any medication?
Undergone surgery in the last 9 months?
Undergone radiotherapy or chemotherapy?
Epileptic?
Smoke?
Undergone any of the following treatments: laser, medical dermabrasion, epidermabrasion, chemical peeling?
Do you exercise or play sports?
Are you on diet?
Do you heal easily?
Do you wear contact lenses?
Email:
*
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Male clients only
Have you ever experienced irritation from shaving?
Do you have ingrown hair?
Do you current using electric shaver?
Date of the last aesthetic treatment
*
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
Do you have any of these problems?
Heart - pacemaker
Thyroid
Hormonal imbalance
Blood pressure
Do you suffer from?
Herpes
Hepatitis B
Hepatitis C
H.I.V.
Rosacea
Claustrophobia
Oedema (heavy legs)
Varicose veins
Allergies
Do you use?
Cleanser
Soap
Exfoliant
Mask
Moisturizer
AHA
Vitamin A acid
Sun products
Medically prescribed skin care
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