CLIENT FORM - Skin care treatments

First Name *

Last Name *

Email *

Date of birth

Phone *

Address *

City *

State *

Postal code *

Country *

Skin Background

What is your natural eye color?

What is your natural hair color?

Do you consider your skin (please choose the best option)

Sensitive

Resilient

Normal

Unsure

Describe your skin in 3-5 words:

What is your skin goal?

Please list your current skincare routine (including brand names)

Have you ever had a bad reaction to anything you put on your face? If so, please describe

Health History

Please list any other medications you are taking

Please list any vitamins or supplements you are taking:

Are you allergic to the following?

Sulfa

Aspirin

Latex

Please list all known allergies:

Have you used Accutane (isotretinoin) in the past 6 months

Yes

Lifestyle

Do you regularly swim in a chlorinated pool?

Yes

Do you smoke tobacco?

Yes

Do you use fabric softeners or dryer sheets?

Yes

Do you work around tar, grease, or chemicals?

Yes

Do you work nights?

Yes

Sometimes

Occupation:

Are you currently under stress? (new job, job loss, wedding, romantic breakup, school, death of a loved one, graduation, difficult home life, long commute, heavily scheduled, new parent, recently moved, medical condition)

Do you spend a lot of time outdoors?

Yes

Women Only: Are you pregnant, trying to become pregnant, or nursing?

Women Only: Are you using a hormonal birth control? If so, please list:

Treatment & Consent

Have you had any of the following treatments in the past 30 days?

Many treatments may consist of surface cleansing, mild chemical exfoliations, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 30 to 90 minutes to complete and are designed to balance, hydrate, clear acne impactions, correct signs of aging and prepare the skin for home care. Implements and equipment used in this facility are disposable or properly sterilized according to the State Board of Cosmetology regulations.

Please read and initial the following carefully:

I have not had any chemical peel of any kind 14 days prior to this treatment. I understand that I cannot have any other treatments performed to my face without consulting Stormie skin & wellness.

I have informed Stormie skin & wellness of any topical or oral medications I am using, including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac), Accutane, or antibiotics.

I have not had any facial waxing within 7 days of this treatment. I will not get waxing for 7 days following this treatment.

I agree not to pick at my acne, as it may inhibit my progress and treatments.

I agreed I have not been exposed to excessive sun or wind and my skin is not irritated in anyway. I understand my skin cannot be compromised to receive treatments.

I agree to wear SPF 30 everyday.

I understand that I may experience much visible peeling, flaking, discoloration, or irritation following this treatment. I agree to follow my homecare to help with healing of my skin.

I recognize that the products Stormie skin & wellness recommends are clinical strength active formulas that are designed to treat problematic skin. Tingling sensations are normal with product application but should not be painful. If I experience pain or discomfort, I will contact the provider.

I understand that controlling acne is best achieved through treatments every two weeks, using homecare as directed, and following all diet and lifestyle recommendations. I understand that without following the suggestions by Stormie skin & wellness, I may not get my desired results.

I have informed Stormie skin & wellness of all health problems that I am aware of.

I understand I cannot return any retail products. No exceptions.

I understand I cannot bring my children to my Stormie skin & wellness appointment.

I agree to Stormie skin & wellness 48 hour rescheduling policy. I will be charged 100% of the service cost for canceled or rescheduled appointments less than 48 hours of the appointment. I understand that if I late cancel or no show more than two times, I will agree to an updated cancellation policy; if I miss or no show again, I can no longer be a client at Stormie skin & wellness.

I consent to photographs taken of my skin for to be used for monitoring treatment progress.

I agree to the above and consent to the treatments performed on me. I agree that I will inform Stormie skin & wellness of any changes to my skin. I agree to follow homecare and post-treatment instructions.

Date

Client name (signature)

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