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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:
*
Check here to receive email updates
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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