New Client Form

Contact Information
Name *
Name
Phone *
Phone
Birth Day
Birth Day
Who do I call if there is an emergency and how are they related to you?
Emergency Contact Phone Number *
Emergency Contact Phone Number
Skin & Health History
Your Skin Type:
Does your job and lifestyle require that you work/play outdoors?
Do you wax your facial skin on a regular basis?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
If yes, was it within the last month?
Are you using? Retin-A
Are you using Benzoyl Peroxide?
Have you ever experienced a reaction to any of the following?
Check all that apply:
Check if you have any of these conditions:
Are you on Accutane?
Are you on Antibiotics?
Are you on Birth Control?
I have read and acknowledged the cancellation policy and will comply accordingly. *
I have read and completed this questionnaire truthfully. 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 are voluntary and I release the company and/or skin care professional from liability.
Date
Date
Todays date