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Date
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Name:
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Date of Birth:
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Gender:
Female
Male
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Cross:
Male to Female
Female to Male
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Address:
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Phone Number:
(include area code)
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Email:
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How did you find us?
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Facial
Back Facial
Peel
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Waxing
Electrolysis
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Face
(name area)
Back
Bikini
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Chest
Underarms
Fingers/Toes
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If waxing or electrolysis client,
current method being used:
(tweezers, wax, razor, depilatories,
other):
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Which of our type of services
have you had before?
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Please check box if answers are yes, also fill-in blanks.
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Medications/Vitamins
regularly taken:
Any past or present health
issues such as:
cancer, heart problems or high
blood pressure, immune disorders,
sinus problems, skin diseases,
urinary or kidney problems,
hysterectomy, fever blisters
or cold sores, diabetes, hormone
imbalance, varicose veins, epilepsy,
thyroid, infectious hepatitis, asthma,
eczema, eczema, epilepsy, chronic
headache
Any special skin problems or
concerns:
(acne, dry, aging, etc.)
Products regularly used:
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Are you under a
physician's
care?
Are you pregnant?
Taking birth control or
hormone replacement?
Wear contacts?
Smoke?
Stress level (0-4)
Skin cancer?
Exercise Regularly?
Glass of water a day?
Drink alcohol?
Have metal implants?
(piercings, pacemakers)
Use Retin-A or acne
drug Accutane?
Any special skin
problems?
(acne, rosacea, dehydrated,
sun damaged,
hyper/hypopigmented,
premature aging)
Have you aver had any
chemical peels,
microdermabrasion,
or resurfacing treatment?
Within the last month?
Are you currently using any
products that contain
glycolic acid, lactic acid,
exfoliating scrubs, any
hydroxy acid product
vitamin A derivatives
(such as retinol?)
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soap
cleanser
toner
moisturizer
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masque
exfoliator
eye products
sunscreen
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Do you consider your skin
to be normal, dry, oily,
combination or sensitive
skin?
What is your coloring?
Very light with freckles,
fair, average, Mediterranean,
Middle Eastern, Black:
Do you: always burn with no
tan, burn easily, sometimes
burn but gradually tan, rarely
burn and always tan, tan, tan
easily?
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Are you taking oral contraceptives,
pregnant, trying to become
pregnant or lactating?
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What is your current shaving system?
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Wet Shave
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Electric
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Do you experience irritation from shaving?
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Do you experience ingrown hairs?
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Skin Care Goals?
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After submitting this form,
your answers will be shown to
you. You may press the back
arrow button on your
computer to get back to this
page.
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For recent reconstructive surgeries, please provide a
physicians release.
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Providing accurate and complete information prior to your
appointment will help us decide your course of treatment
and appropriate products.
Thank You!
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Check box that you understand this is
considered correct info. and you consent to
treatment based on these answers
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