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Please tell us about your skin today...
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First
Client's
Name
First Name
*
Last Name
*
First
Client's
Date of Birth
*
- Month -
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1912
First
Client's
Information
Have you seen a doctor in the past year for a skin order?
*
No
Yes
If yes, please explain.
Are you experiencing any skin problems now?
*
No
Yes
If yes, please explain.
What is your objective for your facial today?
Are there specific areas or issues you'd like to focus on?
Would you like suggestions for home care products to address your concerns?
*
Yes
No
Are you currently under a doctor's care?
*
No
Yes
Please list any diagnosed conditions.
Are you currently taking any:
Prescriptions
Medications
Hormones
Vitamins
None of the above
If yes, please list.
Have you used or are you using (check all that apply):
*
Not using anything
Accutane
Diet tablets
Diuretics
Retin-A
Laxatives
Oral contraceptives
Smoke
Stimulants
Alpha Hydroxy Acid / AHA's
Other
If "other", please explain.
Have you ever undergone cosmetic surgery or had dermabrasion?
*
No
Yes
If yes, please explain.
Do you get injectables (ie Botox)?
*
No
Yes
Most recent approximate date and location?
Are you pregnant?
*
No
Yes
Do you consume alcohol?
*
No
Yes
If yes, how many glasses per week?
Do you have any allergies to:
*
None
Cosmetic ingredients
Pollen
Essential oils
Animals
Other
If "Other", please explain.
Have you ever had a reaction to any treatments?
*
No
Yes
If yes, please explain.
Redness tendency?
*
No
Yes
Sinus problems?
*
No
Yes
Massage preference?
*
Light
Firm
Please select all you use for your home care routine.
*
Cleanser
Soap on face
Toner
Scrub
Masque
Peel
Moisturizer
Serum
Facial Oil
SPF
None of the Above
First
Client's
Signature
*
Type Signature
Draw Signature
Change Font
Accept Signature
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Accept Signature
Clear
Click to Sign
Edit Signature
Parent or Guardian's
Email Address
Email
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A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact
Emergency Contact's Name
*
Emergency Contact's Phone Number
*
Please tell us...
How did you hear about us?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 17 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's
Name
First Name
*
Last Name
*
Parent or Guardian's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
- Year -
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Parent or Guardian's
Information
Have you seen a doctor in the past year for a skin order?
*
No
Yes
If yes, please explain.
Are you experiencing any skin problems now?
*
No
Yes
If yes, please explain.
What is your objective for your facial today?
Are there specific areas or issues you'd like to focus on?
Would you like suggestions for home care products to address your concerns?
*
Yes
No
Are you currently under a doctor's care?
*
No
Yes
Please list any diagnosed conditions.
Are you currently taking any:
Prescriptions
Medications
Hormones
Vitamins
None of the above
If yes, please list.
Have you used or are you using (check all that apply):
*
Not using anything
Accutane
Diet tablets
Diuretics
Retin-A
Laxatives
Oral contraceptives
Smoke
Stimulants
Alpha Hydroxy Acid / AHA's
Other
If "other", please explain.
Have you ever undergone cosmetic surgery or had dermabrasion?
*
No
Yes
If yes, please explain.
Do you get injectables (ie Botox)?
*
No
Yes
Most recent approximate date and location?
Are you pregnant?
*
No
Yes
Do you consume alcohol?
*
No
Yes
If yes, how many glasses per week?
Do you have any allergies to:
*
None
Cosmetic ingredients
Pollen
Essential oils
Animals
Other
If "Other", please explain.
Have you ever had a reaction to any treatments?
*
No
Yes
If yes, please explain.
Redness tendency?
*
No
Yes
Sinus problems?
*
No
Yes
Massage preference?
*
Light
Firm
Please select all you use for your home care routine.
*
Cleanser
Soap on face
Toner
Scrub
Masque
Peel
Moisturizer
Serum
Facial Oil
SPF
None of the Above
Parent or Guardian's
Signature
*
Type Signature
Draw Signature
Change Font
Accept Signature
Clear
Accept Signature
Clear
Click to Sign
Edit 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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