WARNING - Waiver Has Not Been Signed - Please confirm this action
What would you like to achieve from your treatment today?
Your Skin Care
1) Have you ever had a facial treatment before? No Yes, when? 2) Which of the following best describes your skin type? (Please choose one type number)
3) Do you have any special skin problems or concerns pertaining to your face? No YesSpecify:4) Have you ever had chemical peels, laser or microdermabrasion? No YesIn the last month? No Yes5) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? No Yesdescribe:6) Have you used any of these products in the last 3 months? No Yes7) Have you used an acne medication? No Yes
when? Which drug? 8) What skin care products are you currently using? (List brand where known)
12) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
13) What SPF do you use on your face? How often/when? 14) Have you had any recent tanning bed or sun exposure that changed the color of your skin? No Yesspecify:15) Have you experienced Botox, Restylane or Collagen injections? No Yesspecify:Female Clients Only:16) Are you taking oral contraceptives? No Yesspecify:17) Any recent changes to or from your contraceptive treatment? No YesIf so, what and when:18) Are you pregnant No Yes19) Are you lactating? No Yes20) Any menopause problems? No Yesspecify:21) Are you undergoing any hormone replacement therapy? No Yesspecify:Male Clients Only:22) What is your current shaving system? Wet Shave Electric23) Do you experience irritation from shaving? No YesIngrown hairs? No YesPlease circle any conditions that the skin therapist should be aware of:
24) Are you claustrophobic? No YesPlease use this space to complete answers where space was insufficient. (Please include the number of the question)I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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 here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.Client Signature:
(draw your signature)
ashley | ann arbor | michigan | t :734.665.2156 | www.viefit.com
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