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Luna Beauty and Wellness
Client Consultation, Consent & Skin Analysis

The products used at home are a vital part of your treatment plan. Products used may hinder results or cause adverse reaction to treatment. Please seriously consider product recommendations from your esthetician for best results. Luna Beauty and Wellness recommends professional products designed to work with a variety of skin types. Use of these recommended products in conjunction with professional treatments will yield best results.

Cancellation Policy: I agree and accept the 24 hour cancellation policy which states that a minimum of 24 hours’ notice must be given to cancel and/or reschedule an appointment. If I fail to do so I agree that I will pay Luna Beauty & Wellness the full amount for the service. If I have a gift certificate, voucher or membership credit intended for this service I agree to forfeit its value and pay the difference should there be a remaining balance.

Luna Beauty and Wellness reserves the right to refuse service. Any lewd/disrespectful/sexual/inappropriate comments or behavior will terminate the session and I will be liable for payment of the scheduled treatment. 

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous 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 professional from liability and assume full responsibility thereof. I agree to keep Luna Beauty and Wellness as well as the esthetician updated as to any changes in my medical profile and understand that there shall be no liability on the esthetician’s part should I fail to do so.

Today's date: September 28, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
Client's 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.
I confirm that I have read and understand all information on the applicable forms for this treatment or service and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree and give permission for my child to have the above services performed today and going forward as needed. I agree to supervise any home care procedures that are recommended as a result of the treatment. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What are your pronouns? *

Referred by

Occupation *
Do you work/spend a large amount of time outside?*
No
Yes
Have you ever had a facial treatment before?*
No
Yes

If yes, how often?

What are your goals for this treatment? *

What skin care products are you currently using? (List brand & specific product where known)


Cleanser. Is it foamy or milky?

Scrub. Is it fine or course?

Toner

Mask

Eye Product

Serums

Day Moisturizer

Night Moisturizer/Cream

Sunscreen. Do you apply everyday?
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes
Do you wear makeup regularly?*
No
Yes
What areas of concern do you have regarding your skin? (Please check all that apply)
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Puffy eyes
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Cracked/chapped lips
Dark circles

Other

Health & Skin History:

Are you under the care of a physician, dermatologist or other medical professional?*
No
Yes
Have you had any of these health conditions in the past or present? (Please check all that apply)
Cancer
Systemic disease
Spinal injury
Hysterectomy
Heart problem
Arthritis
Eczema
Seizure disorder
Headaches (chronic)
Herpes
Immune disorders
Lupus
Phlebitis, blood clots, poor circulation
Psychological treatment
Keloid scarring
Any active infection
Hormone imbalance
High blood pressure
Thyroid condition
Diabetes
Varicose veins
Asthma
Epilepsy
Fever blisters
Hepatitis
Frequent cold sores
HIV/AIDS
Metal bone pins or plates
Blood clotting abnormalities
Insomnia
Skin disease/skin lesions

Are you currently taking any medications? *
Are you currently pregnant or nursing?*
No
Yes
Are you undergoing any hormone replacement therapy?*
No
Yes
Do you have any metal implants or a pacemaker?*
No
Yes
Do you wear contact lenses?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma*
No
Yes

If yes, describe
Have you received Botox, Restylane or Collagen injections within the last 2 weeks?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) *
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
No, I have never experienced an adverse reaction
Do you get oily throughout the day?*
No
Yes
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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