BLH Beauty New Acne Client Questionnaire

New Acne Client Questionaire
Date
MonthDayYear
Date
Name
First NameLast Name
Email
example@example.com
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Area CodePhone Number
Birthdate
Age
How did you hear about BLH Beauty?

Please list your current skincare routine:
Have you had any bad reaction to anything you put on your face? If so, please list in detail
Are you allergic to the following?
SulfurLatexAspirinOther
Please list any known allergies:
Do you smoke?
Do you regularly swim in a chlorinated pool?
Do you use fabric softeners or dryer sheets?
Do you work around chemicals, tars or grease?
Occupation:
Do you work nights?
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)
Are you a vegetarian or a vegan?
Do you like to spend time outdoors?
Do you develop cold sores/blisters?
Have you used Accutane (isotretinoin) in the past 6 months?
Women Only: Are you pregnant, trying to become pregnant, or nursing?
Women Only: Are you using a hormonal birth control? If so, please list:
Men Only: Do you have shaving/ irritation on your face?

Acne Treatment and Consent:
An acne treatment may consist of surface cleansing, mild chemical peels or steam and exfoliation, application of antibacterial serums, corrective serums and extractions. Treatments take approximately 30 to 75 minutes to complete and are designed to balance, hydrate, clear acne impactions 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 BLH Beauty.
Initial
I have not had any facial waxing within 7 days of this treatment. I will not get waxing for 7 days following this treatment.
Initial
I have informed BLH Beauty of any topical or oral medications I am using, including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac), Accutane, or antibiotics.
Initial
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.
Initial
I recognize that the products BLH Beauty 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 BLH Beauty.
Initial
I understand I cannot bring my pets or children to my BLH Beauty appointment.
Initial
I agree to BLH Beauty's 24 hour rescheduling policy. BLH Beauty will charge 50% of the service cost for canceled or rescheduled appointments less than 24 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 BLH Beauty.
Initial
I agree not to pick at my acne, as it may inhibit my progress and treatments.
Initial
I agree to avoid direct sunlight for at least 3 days following treatment.
Initial
I agree to wear SPF 30 everyday.
Initial
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.
Initial
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 BLH Beauty, I may not get my desired results.
Initial
I have informed BLH Beauty of all health problems that I am aware of.
Initial
I understand I can exchange or return Face Reality products within 30 days of purchase. Products cannot be returned or exchanged after 30 days.
Initial
I understand I cannot return makeup products.
Intiail
I content to photographs taken of my for to be used for monitoring treatment progress.
Initial
I agree to the above and content to the treatments performed on me. I agree that I will inform BLH Beauty of any changes to my skin. I agree to follow homecare and post-treatment instructions.
(Yes or No)
Print Name
First NameLast Name
Name of Parent/ Guardian (if under 18)
First NameLast Name
Signature
Clear
Date
MonthDayYear
Date
Should be Empty:

	Currently Using	Previously Used
Antibiotics
Accutane
Benzoyl Peroxide
Retin A (Vitamin A/ Retinol)
Tazorac
Differin
Epiduo
Azelex
Avita
Cleocin-T
E-mycin -T
Copaxone
Corticosteroids
Quinine
Steriods
Marijana
Cocaine/Speed

	Daily	Weekly	A few times a month	Monthly	Never
Fast Food
Processed Food
Salty Snacks
Milk
Yogurt
Cheese
Other Dairy
Whey or Soy
Peanut Butter
Peanuts
Sushi
Kelp/ Seaweed
MIso Soup
Soy
Seafood
Sugary Foods
Alcohol

New Acne Client Questionaire