Client Profile Card Form

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CLIENT PROFILE CARD
Today’s Date: ___________________Date of Birth _____/_______/____________
Name:___________________________________________ Occupation:___________________________
Address:_______________________________________________________________________________
City/State/Zip:_________________________________________________________________________
Email:_______________________________________________________________________________
Bus Ph: (
) _________________________ Res Ph: (
) ___________________________________
Cell Ph: (
)________________________________
Emergency Contact:______________________________________Phone ________________________
Referred by:___________________________________ Have you ever had a massage? Yes___ No___
Facial? Yes___No___ PhotoRejuvenation? Yes___No___
Microdermabrasion? Yes___No_______
What is your specific concern about your skin?______________________________________________
How long have you noticed your condition?_________________________________________________
Medical: Are you currently or within the last year under any Doctor’s care? Yes____ No _________
Explain: _______________________________________________________________________________
Circle any Health Problems: Diabetes, Thyroid, Heart, Cancer, High or Low Blood Pressure,
HIV/Aids, Epilepsy, Arthritis, Tendenitis, Bursitis, Nail or Foot Fungus, Urinary or Kidney
Problems, Varicose Veins, Hepatis A, B, or C, Circulatory Problems, Depression, Lupus, Pacemaker,
Psoriasis, Scleroderma, Fever Blisters, Eczema, Stroke, Sunburn, Anemia, Fibromyalgia, Stress
related illness, Scoliosis, Chemotherapy, Radiation, Skin Disease, Hormone Problems, Cold hands or
feet, Contact Lens, Blood Disorder, Blood Thinner, Artificial Implants, Phlebitis, Hyper/Hypo
Pigmentation, Claustrophobia, Sinus, Headaches, Contagious Diseases, Joint Swelling, Skin Cancer,
Hysterectomy, Alcoholism, Whiplash, Other_______________________________________________
Are/have you using/taking:
Antibiotics, Accutane, Retin A, Glycolic or Alphahydroxy acids,
Azelex, Differin, Tazarac, Tanning Bed, Diet Tablets, Smoke, Stimulants, Oral Contraceptives,
Laxatives, Diuretics, Other ______________________________If so, How long?__________________
Medications, & Vitamins – List all and why: ________________________________________________
_______________________________________________________________________________________
If you have known allergies, please list them:________________________________________________
Are you allergic to any beauty products that you know of? Yes___ No ___, If so, please let us know
what they are ________________________________________________________________________
Are you allergic to: Aspirin, Glycolic, Any plants, botanicals, Nuts. If yes, please provide their
names: _________________________________________________________________________
Have you undergone surgery recently? Yes____ No____Explain______________________________
________________________________Any Numbness/Stabbing pain anywhere: _________________
Have you had recent plastic surgery? Yes ____ No ____Explain ______________________________
If you recently had surgery, do you have permission from your doctor for a facial ? _______________
Do you have any metal implants/pacemaker? Yes _____ No ____ Explain
_______________________________________________________________________________________
Do you exercise regularly? No ____ Yes ______ Explain ____________________________________
What is your daily consumption of : Water _______oz. Coffee _____ oz. Tea _____ oz. Other ___ oz.
Soft Drinks (Diet/Reg.)______ oz.
Do you have LASH EXTENSIONS? NO_______ YES__________

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