Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Who can we thank for referring you?
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
YES
NO
Have you recently had any type of peel, laser or micro needling performed?
If yes, please explain.
Are you using Retin-a, Renova or Accutane (in the last year)?
If yes, please list strength, length of use, frequency and tolerability.
Are you using any other skin thinning (exfoliating) products and/or drugs on your face or body?
YES
NO
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
YES
NO
How does your skin react to “trauma” (waxing, extractions, cuts, heat, peels)? (ie: redness, raised hives, thick scars, dark spots, etc)
Are you diabetic?
YES
NO
Do you have any allergies that you are aware of?
YES
NO
Are you pregnant or planning to become pregnant?
YES
NO
Do you smoke (cigarettes, vape, etc) ?
YES
NO
Do you have any metal implants or wear a pacemaker?
YES
NO
Have you recently had any surgery or cosmetics injections such as Botox, Juvederm, etc.?
If yes, how recently? Where on your body?
Are you currently taking any medications that could affect your service today? (oral blood thinners, hormones, antibiotics chemotherapy, etc.)
Please list any other illness/condition you may suffer from or are currently being treated for by a medical professional (PCOS, Hormonal imbalances, Herpes/cold sores, vascular issues, thyroid condition, heart conditions, seizures, cancer, etc.)
What are your main areas of concern and/or goals for your skin? :
Please list your morning routine (ie: cleanser, toner, moisturizer) and include brand names if possible:
Please list your evening routine (ie: cleanser, toner, moisturizer) and include brand names if possible:
Please list any weekly or monthly products used (masks, peels, tools) and include brand names if possible:
Client Signature
*
Please note that waxing and exfoliation services do have certain side effects such as skin removal, redness, swelling, tenderness, etc. I give permission to my therapist to perform the procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
