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Client Information
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Name
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Email
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Phone
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DOB
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Address
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City/State/Zip
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Emergency Contact Name
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Emergency Contact Phone
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Referred by:
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Health Information
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Are you taking any medication? If yes, please list.
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Medications
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Do you have any Allergies?
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List allergies. (Medications, food, oils, lotion, etc)
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Are you pregnant? Females only.
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How many weeks?
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Have you had any recent injuries or receiving any medical interventions?
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List any injuries/interventions.
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Do you have any of the medical conditions listed below? If yes, please select them.
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Areas of swelling
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Autoimmune disorder
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Back/neck problems
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Bleeding disorder (blood thinners, hemophilia)
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Blood clots
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Bruise easily
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Bursitis
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Cancer
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Contagious condition (Covid, Flu, HSV, Shingles, etc)
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Diabetes
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Fibromyalgia
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Headaches
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Heart attack
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Heart failure
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Heart valve problem
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Hypertension
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Kidney disease
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Multiple sclerosis
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Neurological condition (i.e. Guillain-Barre Syndrome, myasthenia gravis, etc)
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Neuropathy
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Osteoarthritis
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Osteoporosis
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Phlebitis
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Sciatica
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Seizures
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Stroke
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Tendinitis
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TMJ (temporal mandibular joint disorder)
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Varicose veins
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Vertigo
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What is your area of focus today? (entire face, lower lids, cheeks, etc)
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Areas of broken skin on face or neck?
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If yes, describe location/s
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Have you had any facial surgeries?
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If yes, where
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Please describe any other injuries or health conditions not listed?
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Facial information
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Have you ever had a facial procedure by a professional esthetician before?
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What procedure? How recently?
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Have you had any reactions to skin care products, or cosmetics?
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Describe the reaction and how long ago it occurred.
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How would you describe your skin? Select the one that applies.
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What areas of concern do you have about your skin? Select all that apply.
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When you go out in the sun do you do any of the following? Select the one that applies.
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Do you use any of the products listed?
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Select all that apply.
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Have you recently used Botox, Restylane or Collagen injections recently?
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If yes, which ones and when.
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Areas of focus- Face
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Authorization and Release
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Signature
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Date and time
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