Skincare Treatment Form (Page 3 of 3) in pdf

Skincare Treatment Form - Continued

14) What SPF do you use on your face? ____________ How often/when? _____________

15) What SPF do you use on your body? ___________ How often/when? _____________

16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?

m No m Yes

specify: ____________________________________________________________________________________

17) Have you experienced Botox, Restylane or Collagen injections?

m No m Yes

specify: ____________________________________________________________________________________

Female Clients Only:

18) Are you taking oral contraceptives?

m No m Yes

specify: ____________________________________________________________________________________

19) Any recent changes to or from your contraceptive treatment?

m No m Yes

If so, what and when: _______________________________________________________________________

20) Are you pregnant or trying to become pregnant?

m No m Yes

21) Are you lactating?

m No m Yes

22) Any menopause problems?

m No m Yes

specify: ____________________________________________________________________________________

23) Are you undergoing any hormone replacement therapy?

m No m Yes

specify: ____________________________________________________________________________________

Male Clients Only:

24) What is your current shaving system? Wet shave o Electric o

25) Do you experience irritation from shaving? m No m Yes

Ingrown hairs? m No m Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

________________________________________________________________________________________________

Future Appointments/Contact:

May I call you at your home, work or cell phone number to confirm future appointments? m No m Yes

May I contact you via mail/email about future promotions and news? m No m Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ-

ous 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 profes-

sional from liability and assume full responsibility thereof.

Client Signature: _____________________________________________________________ Date:______________

member

Associated Skin Care Professionals

Skincare Treatment Form Page 3