Home
About
Services
Other services
Chemical Resurfacing
Facial Treatments
men's skincare
Waxing
Policies
Contact
Menu
148 N. Thirteenth St #100
Grover Beach Ca 93433
(805) 825-8546
"Beautifying the Five Cities area"
Your Custom Text Here
Home
About
Services
Other services
Chemical Resurfacing
Facial Treatments
men's skincare
Waxing
Policies
Contact
New Client Form
Contact Information
Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Birth Day
MM
DD
YYYY
Emergency Contact Name & Relation
*
Who do I call if there is an emergency and how are they related to you?
Emergency Contact Phone Number
*
(###)
###
####
Skin & Health History
What are your skin goals and / or concerns?
Your Skin Type:
Normal/Combo
Oily
Dry
Mature and Aging
Sensitive
Mild Acne
Moderate Acne
What skin products are you currently using?
What makeup products are you currently using?
Does your job and lifestyle require that you work/play outdoors?
Yes
No
Sometimes
Do you wax your facial skin on a regular basis?
Yes
No
If so, when was the last time?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
Yes
No
If yes, was it within the last month?
Yes
No
Are you using? Retin-A
Yes
No
Are you using Benzoyl Peroxide?
Yes
No
Tell me about any allergies or sensitiveness you have:
Have you ever experienced a reaction to any of the following?
cosmetics
medicine
iodine (shellfish)
latex
pollen
food or fruit
animals
fragrance
alpha hydroxy acids
sunscreens
Tell me about any health issues you have:
Check all that apply:
Cancer
Circulatory issues
Arthritis
Hormonal imbalances
Diabetes
Lactating
Chemotherapy
High blood pressure
Hysterectomy
Thyroid
Pregnant or about to become pregnant
Recent surgeries
Eczema
Tell me about any medications you take:
Check if you have any of these conditions:
Accutane
Antibiotics
Birth Control
Tell me about any medications you take:
Are you on Accutane?
Yes
No
Are you on Antibiotics?
Yes
No
Are you on Birth Control?
Yes
No
I have read and acknowledged the cancellation policy and will comply accordingly.
*
Yes
Signature
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.
Date
Todays date
MM
DD
YYYY
Thank you!
Click here to view our cancelation policy.
