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FACIAL FORM

FILL YOUR DETAILS

Tell us a bit about your health history. In order to better serve you we ask that you please answer the following questions as accurately as possible. READ TERMS and CONDITIONS

Age
Referred By:
Health History
Are you presently under a physicians care for current conditions?
Have you undergone any surgery within the last year?
What areas of concern do you have regarding your skin?
Have you ever or are you currently being affected by the following:
Do you smoke?
Do you have any allergies to cosmetic, foods, or drugs?
Are you claustrophobic?
Skin Information:
Is this your 1st Facial?
What skin care products are you currently using?
Are you currently using (or have you used in the past):
Are you now using or have you ever used Accutane?
Oil Secretion
Do you experience?
Moisture Hydration:
How many alcoholic beverages do you consume weekly?
Do you experience these conditions?
Capillary Activity:
Do you burn easily in moderate sunlight?
Do you burn easily when nervous?
Do you have a tendency towards redness?
Do you suffer from sinus problems?
What water temperature do you cleanse with?
Nerve Activity:
What do you consider your pin threshold to be?
What type of massage pressure do you prefer?
Female Clients Only:
Are you taking oral contraception
Are you pregnant or trying to become pregnant?
Are you lactating?
Male Clients Only:
What is your current shaving system?
Do you ever experience irritation from shaving?
Do you experience ingrown hair?
Disclaimer

The purpose of this form is to ensure that all safety precautions are taken to provide you (the client) with quality care and optimal outcomes of the services provided.  The provider is not responsible for any negative outcomes due to withheld information.  This information will remain on file for one year and will be stored in accordance with HIPPA guidelines, we will not share your information and it will be kept confidential.

*By signing this form, you (the client) are stating that you have read and understand the above disclaimer and are allowing the provider to perform services requested.

Thanks for submitting!

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