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skin care
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book now
consent forms
waxing consent form
microdermabrasion consent form
skin health history consent form
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Skin Health History Consent Form
Please answer the following confidential questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin care needs.
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Name
*
First
Last
Date
*
MM slash DD slash YYYY
Age
*
Date of Birth
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Email
List of medications taken:
Allergies:
Are you currently under the care of a physician?
*
Yes
No
If yes, for what conditions?
Are you pregnant?
Yes
No
Please select any of the following you have been treated for
*
Skin Disease
Acne
Cold Sores
High Blood Pressure
Diabetes
Hormone Therapy
None of the above
Your daily stress level is:
*
Low
Medium
High
How much water do you drink everyday?
*
Do you have metal implants in your body?
*
Yes
No
If so, where so?
Ethnic Background
Occupation
Your Skin
On a scale of 1 to 10 (1= horrible, 10= fantastic), please rate how you feel about the overall look of your skin:
*
Please enter a number from
1
to
10
.
How often do you wear facial sunscreen?
Everyday
Occasionally
Only when I'm outside.
Never
If you go into the sun without sunscreen, how often will you burn?
Always
Most of the time
Sometimes
Rarely burn
Very rarely
I never burn
When was your last sunburn?
Please list any procedures you've had over the last 12 months:
What skin care line are you using?
Describe your daily skin care routine:
What is the most important improvement you'd like to see in your skin?
Do you receive any of the following procedures regularly?
Waxing
Facial Injections
Microdermabrasion
Chemical Peels
None
Do you receive any of the following procedures regularly?
*
Waxing
Facial Injections
Microdermabrasion
Chemical Peels
None
