Name: Date of Birth: Address: Home Phone: Business Phone: Cell Phone: address: Employer: Occupation: m No m Yes.
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1 Client Cnsultatin Date: Name: Date f Birth: Address: Hme Phne: Business Phne: Cell Phne: address: Single: Married: If yes, anniversary date: Emplyer: Occupatin: Des yur jb require that yu wrk utdrs? Referred by: What wuld yu like t achieve frm yur treatment tday? Yur Skin Care 1) Have yu ever had a facial treatment befre?, when? 2) Have yu ever had a bdy spa treatment befre?, when? Massage: Salt glw: Seaweed wrap: Mr mud: Bdy scrub: Other: 3) Which f the fllwing best describes yur skin type? (Please circle ne type number) I Creamy cmplexin Always burns easily, never tans II Light Cmplexin Always burns, tans slightly III Light/Matte Cmplexin Burns mderately, tans gradually IV Matte Cmplexin Seldm burns, always tans well V Brwn Cmplexin Rarely burns, deep tan VI Dark Brwn Cmplexin Rarely burns, deeply pigmented 4) D yu have any special skin prblems r cncerns pertaining t yur face r bdy? m Yes m N 5) Have yu ever had chemical peels, laser r micrdermabrasin? In the last mnth? 6) D yu use Retin-A, Renva, Adapalene Hydrxyl Acid r Retinl/vitamin A derivative prducts? describe: Cntinued a member
2 Client Cnsultatin cntinued 7) Have yu used any f these prducts in the last 3 mnths? 8) Have yu used an acne medicatin?, when? Which drug? Sap Tner Mask Eye Prduct Cleanser Day Misturizer Exfliatr Scrubs Shwer Gels Bdy Ltins Sunscreen SPF Night Misturizer/Cream Makeup Prducts 9) What skin care prducts are yu currently using? (List brand where knwn) 10) Have yu recently used any self-tanning ltins, creams r treatments?, specify: 11) Have yu used any f the fllwing hair remval methds in the past six weeks?, circle all that apply. Shaving Waxing Electrlysis Plucking Tweezing Stringing Depilatries 12) What areas f cncern d yu have regarding yur: Skin: (Please check any that apply and explain) Breakuts/acne Blackheads/whiteheads Excessive il/shine Rsacea Brken capillaries Redness/ruddiness Sun spt/liver spt/brwn spt Uneven skin tne Sun damage Wrinkles/fine lines Dull/dry skin Flaky skin Dehydrated Eyes: dehydrated wrinkles puffiness dark circles Other: Lips: dehydrated cracked/chapped lips Other: 13) Have yu ever had an allergic reactin t any f the fllwing? (Please check any that apply and explain) If yes, please explain: Csmetics Medicine Fd Animals Sunscreens Idine Pllen AHAs Fragrance Shellfish Latex Drugs Cntinued a member
3 Client Cnsultatin cntinued 14) What SPF d yu use n yur face? Hw ften/when? 15) What SPF d yu use n yur bdy? Hw ften/when? 16) Have yu had any recent tanning bed r sun expsure that changed the clr f yur skin? 17) Have yu experienced Btx, Restylane r Cllagen injectins? Female Clients Only: 18) Are yu taking ral cntraceptives? 19) Any recent changes t r frm yur cntraceptive treatment? If s, what and when: 20) Are yu pregnant r trying t becme pregnant? 21) Are yu lactating? 22) Any menpause prblems? 23) Are yu underging any hrmne replacement therapy? Male Clients Only: 24) What is yur current shaving system? Wet shave Electric 25) D yu experience irritatin frm shaving? Ingrwn hairs? Please use this space t cmplete answers where space was insufficient. (Please include the number f the questin) Future Appintments/Cntact: May I call yu at yur hme, wrk r cell phne number t cnfirm future appintments? May I cntact yu via mail/ abut future prmtins and news? I understand, have read and cmpleted this questinnaire truthfully. I agree that this cnstitutes full disclsure, and that it supersedes any previus verbal r written disclsures. I understand that withhlding infrmatin r prviding misinfrmatin may result in cntraindicatins and/r irritatin t the skin frm treatments received. The treatments I receive here are vluntary and I release this institutin and/r skin care prfessinal frm liability and assume full respnsibility theref. Client Signature: Date: The Skin Studi member
4 Client Cnsent Micrdermabrasin I,, have read the abve infrmatin and initialed each sectin t indicate that I fully understand what t expect. If I have any questins r cncerns, I will address these with my skin therapist. I give permissin t my therapist,, Stephanie Czech/The Skin Studi t perfrm the micrdermabrasin prcedure we have discussed and will hld him/her and his/her staff harmless frm any liability that may result frm this treatment. I understand he/she will take every precautin t minimize r eliminate negative reactins such as blisters, sres, r ther reactins, as much as pssible. I have given an accurate accunt f any ver-the-cunter r prescriptin medicatins that I use regularly and I am nt presently using istretinin (Accutane). I have nt had any facial surgical prcedures r ther chemical peels r skin treatments that I have nt disclsed t my therapist. I am nt ingesting r using tpically any ther verthe-cunter prduct r prescriptin medicatin/agent that has nt been disclsed t my therapist. I am nt presently pregnant r lactating and I am ver the age f eighteen (18). I have nt had any recent radiactive r chemtherapy treatments, sunburn, windburn, r brken skin. I have nt recently waxed r used a depilatry (such as Nair) n the area t be treated. I d nt have a histry f kelidal scarring, excessive telangiectasia, rsacea, bacterial skin infectins, fungal infectins, viral infectins, pen lesins r rashes, active acne, any aut immune disease, r any ther existing cnditin that may interfere with the psitive utcme f this treatment. I cnsent t the taking f phtgraphs t mnitr treatment effects, as desired r recmmended by my therapist. My expectatins are realistic and I understand that the results are nt guaranteed. I agree that I am willing t fllw recmmendatins by my esthetician fr hme care. I will be respnsible fr fllwing hme regimens that can minimize r eliminate pssible negative reactins, including recgnizing the imprtance f adhering t a sunscreen and aviding the sun/tanning bths and extreme weather cnditins. I agree t use a misturizer specifically recmmended by my esthetician and I acknwledge that I have been infrmed f the pssible negative reactins and the expected sequence f the healing prcess (dryness, irritatin, redness, and peeling f the skin). In the event that I may have additinal questins r cncerns regarding my treatment r suggested hme prduct/pst-treatment care, I will cnsult my therapist immediately. I understand the ptential risks and cmplicatins and have chsen t prceed with the treatment after careful cnsideratin f the pssibility f bth knwn and unknwn risks, cmplicatins, and limitatins. I agree that this cnstitutes full disclsure, and that it supersedes any previus verbal r written disclsures. I certify that I have read, and fully understand the abve paragraphs and that I have had sufficient pprtunity fr discussin t have any questins answered. Client Name (printed) Client Name (signature) Date Esthetician Date The Skin Studi member
5 Client Cnsent Chemical Peels I,, have read the belw infrmatin and initialed each sectin t indicate that I fully understand what t expect. If I have any questins r cncerns, I will address these with my skin therapist. I give permissin t my skin therapist, Stephanie, Czech/The Skin Studit perfrm the chemical treatment we have discussed and will hld him/her and his/her staff harmless frm any liability that may result frm this treatment. I understand my skin therapist will take every precautin t minimize r eliminate negative reactins such as blisters, sres, r ther reactins, as much as pssible. I d understand that, very rarely, permanent damage ccurs. I have given an accurate accunt f any ver-the-cunter r prescriptin medicatins that I use regularly, and I am nt presently using (nr have I used within the last year) istretinin (Accutane), Retin-A, Acyclvir r tranquilizers. I have nt had any facial surgical prcedures, piercings, tatts, permanent csmetics, r ther chemical peels r skin treatments that I have nt disclsed t my skin therapist. I am nt ingesting r using tpically any ther ver-the-cunter prduct r prescriptin medicatin/agent that has nt been disclsed t my skin therapist. I am nt presently pregnant r lactating and I am ver the age f eighteen (18). I have nt had any recent radiactive r chemtherapy treatments, sunburn, windburn r brken skin. I have nt recently waxed r used a depilatry (such as Nair) n the area t be treated. I d nt have a histry f kelidal scarring, diabetes, any aut immune disease, active herpes blisters, r any ther existing cnditin that may interfere with the psitive utcme f this treatment. I understand that I shuld nt have a chemical peel if I intend t cntinue t have excessive sun expsure. It has been explained t me that the treated area will be mre sensitive t the sun as a result f the treatment and will require regular use f sunscreen. I cnsent t the taking f phtgraphs t mnitr treatment effects, as desired r recmmended by my therapist. My expectatins are realistic and I understand that the results are nt guaranteed and that fr maximum results, mre than ne applicatin may be required. The rate f imprvement f my skin depends n my age, skin type and cnditin, degree f sun/envirnmental damage, pigmentatin levels, r acne cnditin. I understand that this prcedure is expected t make the skin feel uncmfrtable while being applied, but agree t infrm the skin prfessinal immediately if I have cncerns r am verly uncmfrtable during treatment r after I return hme. I agree that I am willing t fllw recmmendatins by my therapist fr hme care. I will be respnsible fr fllwing hme regimens that can minimize r eliminate pssible negative reactins, including recgnizing the imprtance f adhering t a sunscreen and aviding the sun/tanning bths and extreme weather cnditins. I agree t use a misturizer specifically recmmended by my therapist and I acknwledge that I have been infrmed f the pssible negative reactins (intense erythema, welts, scabs) and the expected sequence f the healing prcess (dryness, irritatin, redness, and peeling f the skin). In the event that I may have additinal questins r cncerns regarding my treatment r suggested hme prduct/pst-treatment care, I will cnsult my therapist immediately. I understand the ptential risks and cmplicatins and have chsen t prceed with the treatment after careful cnsideratin f the pssibility f bth knwn and unknwn risks, cmplicatins, and limitatins. I agree that this cnstitutes full disclsure, and that it supersedes any previus verbal r written disclsures. I certify that I have read, and fully understand the abve paragraphs and that I have had sufficient pprtunity fr discussin t have any questins answered. Client Name (printed) Client Name (signature) Date Esthetician Date The Skin Studi member
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