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Please fill out this Skin Care Form before undergoing a facial with Lisa Primps.

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

 

December 13, 2018

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How did you hear about out facility?*
Word of mouth
Social Media
Location
Other

If other please explain:

For your safety and well being we would like you to answer a few health related questions.This information will remain confidential.


What are your primary skin concerns?
Do you have history of chronic acne?*
No
Yes

If yes please explain:
Do you have history of chronic skin sensitivity?*
No
Yes

If yes please explain:
Do you have a history of any allergies (this includes, medications, food, fabrics, etc.)?*
No
Yes

If yes please explain:
Have you ever taken Accutane?*
No
Yes

Please list any oral medications or supplements you're taking:
Do you have a history of cold sores?*
No
Yes

If yes, how frequently?
Have you used facial waxes or depilatories in the past 3-4 weeks?*
No
Yes
Do you use Retinol creams, Retin A, or other topical or oral skin medications?*
No
Yes

If yes, please explain:

Please list any medical conditions you may have.
Have you ever had facial peels, laser rejuvenation or microdermabrasion/dermabrasion?*
No
Yes

If yes, please explain.
Do you wear contact lenses?*
No
Yes
Do you use SPF?*
No
Yes

If yes, how often?
Do you work/play in the sun?*
No
Yes
Do you use tanning beds?*
No
Yes
Do you consider your skin sensitive?*
No
Yes
Do you ever experience breakouts?*
No
Yes

What products do you use weekly?

The following questions are for women only. If you are male please select N/A.

Are you pregnant?*
No
Yes
N/A
Are you lactating?*
No
Yes
N/A
Premenstrual breakouts?*
No
Yes
N/A
Are you taking birth control pills?*
No
Yes
N/A

Other comments:

Please feel free to communicate during your facial about the comfort of the pressure and/or technique being used. The intent of your facial is therapeutic in nature and may be terminated at any time by either party.


Today's date
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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