New Client Form

This form must be filled out as completely as possible by every new client and updated by returning clients with changing skin and health conditions, before services can be offered.

Name *
Name
Phone *
Phone
Emergency Contact Phone Number *
Emergency Contact Phone Number
Birthday
Birthday
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