New Client Form

Today's Date *
Today's Date
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone Number *
Phone Number
Does your work require that you work outdoors?
Have you ever had a facial before? *
2) Have you ever had a body spa treatment before? *
Message? *
Salt glow? *
Seaweed wrap? *
Moor mud? *
Body scrub? *
3) Which of the following best describes your skin type? (Please check one type) *
4) Do you have any special skin problems or concerns pertaining to your face or body? *
5) Have you ever had chemical peels, laser or microdermabrasion? *
In the last month? *
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? *
7) Have you used any of these products in the last 3 months? *
8) Have you used an acne medication? *
9) What skin care products are you currently using? (List brand where known). If none write "None" or "NA"
10) Have you recently used any self-tanning lotions, creams or treatments? *
11) Have you used any of the following hair removal methods in the past six weeks? *
Check all that apply:
12) What areas of concern do you have regarding your: Skin: (Please check any that apply)
Eyes: *
Lips:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
15) Have you had any recent tanning bed or sun exposure that changed the color of your skin? *
16) Have you experienced Botox, Restylane or Collagen injections? *
17) Female Clients Only: Are you taking oral contraceptives?
18) Any recent changes to or from your contraceptive treatment? *
19) Are you pregnant or trying to become pregnant?
20) Are you lactating?
21) Any menopause problems?
22) Are you undergoing any hormone replacement therapy? *
23) Male Clients Only: What is your current shaving system?
24) Do you experience irritation from shaving? *
Ingrown hairs?
Future Appointments/Contact: May I call you at the number you provided to confirm future appointments? *
May I contact you via mail/email about future promotions and news? *
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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 profes- sional from liability and assume full responsibility thereof. *