New Client Registration Form printable pdf download

Name: ____________________________________________________Date of Birth: _______________

Address: ____________________________________________________________________________

City: __________________________________ State: _________________ Zip: ___________________

Phone: ________________________________ Today’s Date: _________________________________

E-mail Address: ______________________________________________________________________

How would you like us to contact you? Email ! Text ! Mail ! Phone !

How did you hear about Facials by Bonnie: _________________________________________________

Have you had a facial before? Yes ! No ! Have you had a peel before? Yes ! No !

What are your main skin concerns? (Check all that apply)

! Acne

! Dehydration(tightness)

! Blemishes

! Dryness (tightness/flakiness)

! Oiliness

! Lines and wrinkles

! Brown Spots/Sun spots

! Large pores

! Clogged pores/blackheads

! Age prevention

! Loss of tone/lack of firmness

! Other: __________________________

! Redness/sensitivity

________________________________

! Rosacea

________________________________

! Easily irritated by products

What is the MAIN purpose of your visit today?

! Acne treatment

! Deep pore cleansing and extractions

! Anti-Aging

! Relaxation & pampering

! Other: ________________________________________________________________________

Do you prefer extractions when you have a facial?

! Yes, my skin needs lots of extractions

! No, I prefer not to have extractions

If you prefer extractions with you facial please read the following:

Extractions are a corrective technique that gently and safely removes blackheads drains inflamed acne

impactions and releases trapped ingrown hair where possible. Side effects of extractions include mild

temporary tenderness, redness, swelling, sensitivity, flaking and small scabs. Superficial dark spots can

occur at extraction sites and very in the time they take to fade.

We cannot guarantee any lesion will not recur at a later date.

Given the time constraints we cannot guarantee every pimple, blackhead and ingrown hair can be

extracted during a facial.

If you would like extractions, please initial to acknowledge the above statement: _______

New Client Registration Form