New Patient History Form

New Patient History Form

























YesNo(if yes, please provide additional information below)

YesNo(if yes, please provide additional information below)

YesNo(if yes, please provide additional information below)

YesNo(if yes, please provide additional information below)

YesNo (if yes, please provide additional information below)

YesNo



YesNo

YesNo
YesNo


YesNo
HighMediumLow


YesNo

YesNo
YesNo
YesNo
YesNo

WaterCaffeineAlcohol
YesNo

YesNo
YesNo
InfrequentlyFrequentlyRegularly
YesNo
YesNo
YesNo
RashIrritationPeelingSun SensitivityBreakout
CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther



Female Clients Only:

YesNo

YesNo

YesNo
YesNo
YesNo

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Please sign your name below