Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

####

Client’s Skin Type *

Fair- always burns, never tans

Light skin tones- can burn, sometimes tans

Medium to olive skin tones, tans easily

Light brown to medium brown skin tones

Brown, moderately pigmented skin

Dark brown/black skin tones

Do you use moisturizer? *

Yes

No

Are you on a special diet? *

Yes

No

Have you ever had a facial? *

Yes

No

Do you give yourself facials at home? *

Yes

No

Are you currently under the care of a physician for any reason? *

Yes

No

For the following, please check any that are applicable to you. *

Medications, supplements, or vitamins

Seasonal Allergies

Accutane

Antibiotics

Birth Control

Hormones

Aspirin, ibuprofen usage

Retin-A, Tretinoin

Metrogel, MetroCream

Glycolic Acid

Antidepressants

Sun Reaction

Medication Allergies

Food Allergies

Aspirin Allergy

Latex Allergy

Lidocaine Allergy

Hydrocortisone Allergy

Hydroquinone Allergy

Diabetes

Smoking History

Cold Sores, Herpes

Bleeding Disorder

AutoImmune Disorder, HIV

Pregnant/ planning to be

Nursing

Pacemaker

Implants of any kind

Migraine Headaches

Glaucoma

Cancer

Arthritis

Hepatitis

Thyroid Imbalance

Seizure Disorder

Active Infection

Skin Radiation in last 3 months

Acne

Melasma

Tattoos, Perm makeup, microblading

Vitiligo

Keloid Scarring

Skin/Laser Treatments

Botox

Fillers

Hair Removal

Chemical Peels

Sun Exposure/tanning bed or self tanner

None of the Above

*

I certify that the proceeding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical and health conditions and to update this information at subsequent visits. A current history is essential for the provider to execute appropriate treatment procedures. I have signed the consent form for this procedure. I had the opportunity to ask questions prior to the treatment. I accept arbitration as a means of resolution for practice liability.