Client Cnsultatin Date: Name: Date f Birth: Address: Hme Phne: Business Phne: Cell Phne: E-mail 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
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
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/email 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
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
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