Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you have any known allergies (e.g., latex, nuts, ingredients in skincare products)?

Yes

No

Are you currently taking any medications, including topical treatments? - Yes / No

Yes

No

Do you have any skin conditions (e.g., eczema, psoriasis, acne)?

Yes

No

Have you had any recent surgeries or cosmetic procedures?

Yes

No

Do you have any chronic conditions or medical issues that we should be aware of (e.g., diabetes, heart conditions)?

Yes

No

How would you describe your skin type?

Check all that apply

Normal

Oily

Dry

Combination

Sensitive

Have you had any adverse reactions to skincare products in the past?

Yes

No

Do you smoke?

Yes

No

Do you follow any specific diet or have any dietary restrictions?

Yes

No

I acknowledge that the information provided above is accurate and complete to the best of my knowledge. - I understand that the esthetician will use this information to provide the best possible care and that I must inform the esthetician of any changes to my health or skincare routine.

Yes, I agree