Client Check-In
Required for all returning clients and to be filled and submitted prior to appointment.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Your Health
A complete health history helps us ensure it is safe to provide you with treatment. All information is confidential.
Are you taking any prescription medications (topical or internal)?
*
Yes
No
If Yes, please list:
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?
*
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Any known allergies?
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Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
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Yes
No
If yes, please specify what and date last used
Do you have any of the following symptoms?
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Fever
Cough
Shortness of Breath
Sore Throat
Chills
Fatigue
Body Aches
No Symtoms
Have you travelled out of state or internationally within the last 14 days?
*
Yes
No
Have you had close contact with a person diagnosed with COVID-19?
*
Yes
No
Have you been advised to quarantine?
*
Yes
No
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. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
Yes
Signature
*
Submit
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