Totally Refreshed Steam, Spa and Salon

Esthetics


Confidential Client History & Consent Form

    

     

 

Gender

 


General Info

 

Have you been under the care of a physician, dermatologist, or the other medical professional within the past year?

Any recent Surgery, including plastic surgery?

 

Have you had any of the following health conditions in the past or present?

Do you Smoke?


Do you follow a restricted diet?

 

What is your stress level?

Do you wear contact lenses?

Have you been exposed to the sun or a tanning be within the last 48 hours?

Do you use or have you ever used Adapalene Hydroxl Acid, Glycolic Acid, AHA, Accutane, Retin-A, Renova, Deferin, Salicylic Acid or any vitamin A derivative product (Accutane)?

 

Have you ever experienced an allergic reaction to any of the following?

 

Have you ever experienced claustrophobia

I consent to photos being used for office use.

I consent to photos being used for advertising.


Female Clients Only

Are you taking any oral contraceptives

Are you pregnant or trying to become pregnant?

Are you experiencing any menopause problems?


Wavier

I understand, have and fully completed this questionnaire truthfully. I agree that constitutes full disclosure, and that it supersede any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin form treatments received. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Totally Refreshed Steam and Spa and my esthetician from liability and assume full responsibility thereof.

Leave this empty:

Totally Refreshed Steam, Spa and Salon https://totallyrefreshedsteamandspa.com
Signature Certificate
Document name: Esthetics
Unique Document ID: d6de18595b5d852ad3123ab3304b749b204e54e0
Timestamp Audit
April 23, 2018 1:20 pm MSTEsthetics Uploaded by Totally Refreshed - totallyrefreshedwaviers@gmail.com IP 184.68.98.146
April 23, 2018 2:54 pm MSTTotally Refreshed Wavier - totallyrefreshedwavier@gmail.com added by Totally Refreshed - totallyrefreshedwaviers@gmail.com as a CC'd Recipient Ip: 184.68.98.146
April 23, 2018 2:58 pm MSTTotally Refreshed Wavier - totallyrefreshedwavier@gmail.com added by Totally Refreshed - totallyrefreshedwaviers@gmail.com as a CC'd Recipient Ip: 184.68.98.146
April 23, 2018 2:59 pm MSTTotally Refreshed Wavier - totallyrefreshedwavier@gmail.com added by Totally Refreshed - totallyrefreshedwaviers@gmail.com as a CC'd Recipient Ip: 184.68.98.146
April 23, 2018 3:00 pm MSTTotally Refreshed Wavier - totallyrefreshedwavier@gmail.com added by Totally Refreshed - totallyrefreshedwaviers@gmail.com as a CC'd Recipient Ip: 184.68.98.146