New Client Form 

Contact Information
Name *
Phone *
Address *
Emergency Contact Number
Emergency Contact Number
Personal Information
Date of Birth
Date of Birth
Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Any recent surgery, including plastic surgery?
Any skin cancer?
Have you had any piercings, tattoos, or permanent cosmetics?
Have you ever had a body spa treatment before?
Have you had any of these health conditions in the past or present?
Has your physician discussed concerns about raising your body temperature?
Do you follow a restricted diet?
Do you follow a regular exercise program?
What is your stress level?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
Have you used any of these products in the last 3 months?
Have you used an acne medication?
Do you form thick or raised scars from cuts or burns?
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Do you experience any problems sleeping?
Do you wear contact lenses?
Have you been exposed to the sun or used a tanning bed in the last 48 hours?
How frequently are you exposed to the sun or use a tanning bed?
Do you have any metal implants or wear a pacemaker?
Have you ever experienced claustrophobia?
Do you suffer from sinus problems?
Have you ever had an adverse reaction after using any skin care product?
Have you ever had an allergic reaction to any of the following?
Female Clients Only
Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatment?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?
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.