Client Information Name First Name Last Name Gender Male Female Prefer Not to Say Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Line Top 3 Skincare Concerns * Line Pregnant * Yes No Breastfeeding * Yes No Do you smoke? * Yes No Health Conditions * Past Surgeries * Have you been diagnosed with cancer? When was your last treatment? * List of your current medications Prescription Topicals Allergies (include aspirin + iodine) Line Previous Treatments * Facials Microdermabrasion Chemical Peels Waxing Tanning Laser Therapy Massage When was the last date of your previous treaments? Please indicate if you had any complications. * Skin Conditions * please check all that apply Skin Infection Herpes (cold sores) Keloids/ Excessive Scarring Sun Sensitivity Skin Cancer Poor Healing Tattoos/ Perm Makeup Easy Bruising Eczema Psoriasis Lymph Nodes Removed Diabetes How would you describe your skin? * Dry Oily Normal Combination Take me step by step of your current skincare routine and the products you are using. * Thank you!
