CLIENT INFORMATION All information collected for the benefit of treatments. Your details are kept strictly confidential at all times. Returning clients,any changes since last visit? If yes please indicate changes on form. Yes No CLIENT NAME * First Name Last Name DATE OF BIRTH * MM DD YYYY GENDER M F Other ADDRESS * PHONE NUMBER * (###) ### #### EMAIL * WHAT ARE YOUR TOP 3 SKINCARE CONCERNS: * MEDICAL HISTORY: Pregnant? Yes No Breastfeeding? Yes No Do you smoke? Yes No Health Conditions: Have you ever been diagnosed with Cancer? Yes No (last treatment date) Have you in the past or present or had any of the following problems? (circle) Epilepsy, Diabetes, Thyroid, Heart Problems, Cancer, Hysterectomy, Hormonal Imbalance, Depression, High or Low Blood Pressure, Other: Have you had plastic surgery? Yes No Date Description: Are you currently using Retin-A, Retinal, AHA or any peeling agent? If so; How Long: Strength: ResuIts: Do you suffer from claustrophobia or anxiety? Yes No Any known allergies to: Cosmetics, Food, Medication, Animals, Pollens or Metals? Do you have a tendency to keloid scar? Yes No Have you had a skin peel in the past 2 years? Yes No ResuIts: Date Have you been under a physicians care during the past 3 years? * Yes No Are you currently taking medication? * Yes No How Long: Name: Are you currently taking accutane or roaccutane? * Yes No How Long: Dietary or Herbal Supplements or Vitamin * Yes No How Long: Name: How much water do you drink daily? ( ) glasses PREVIOUS TREATMENTS Facials Yes No Last treatment: Any complications? Dermabrasion Yes No Last treatment: Any complications? Chemical Peels Yes No Last treatment: Any complications? Injectables Yes No Last treatment: Any complications? Waxing Yes No Last treatment: Any complications? Tanning Yes No Last treatment: Any complications? Laser Therapy Yes No Last treatment: Any complications? Light Therapy Yes No Last treatment: Any complications? Microcurrent Yes No Last treatment: Any complications? Massage Yes No Last treatment: Any complications? TREATMENT PREFERENCES What are your main concerns or goals for today's session? * Relaxation Acne Treatment Anti-Aging Moisturizing Other (Please specify): How often do you usually receive facial treatments? * This is my first time Occasionally (less than once a month) Regularly (once a month or more) SKINCARE What type of skin do you feel you have? * Dry Oily Normal Combination What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.) Have they achieved the results you want? * Yes No Do you use sunscreen daily? * Yes No CONSENT TO TREATMENT I understand that the treatments I receive here are for the purpose of stress reduction and relief from muscular tension or spasm. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that facial treatments should not be construed as a substitute for medical examination, diagnosis, or treatment. Client Signature * Date MM DD YYYY Do you give permission to take photographs and videos of you for the purpose of posting on Beauty by Natural Rejuvenation Studio social media and website? * Yes No Thank you! Facial Massage Consent Form
