New Client Information Form

New Client
Name *

First Name Last Name
Which Email address should we use? (Used for appointment verification and reminders) *
Today's Date *

- Month - Day Year

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mobile Number (Used for appointment notifications) *

- Area Code Phone Number
What Type of phone is this? *

Cell Phone Home Phone Other
What's your birthday?

- Month - Day Year
Lifestyle
Work Life

Stressful Hazardous Physical Sedentary
Leisure

Outdoorsy Sports Sedentary Partier Risxy/Thrill-Seeker
Nutrition
Time of main daily meal
Number of take-out meals per week
How many meals a day? Portion sizes?
A brief summary of your daily or weekly meal habits
Type of food groups eaten per week

Type of food groups eaten per week:

	0	1	2-3	4-5	6+
Grains/Breads
Fruits
Vegetables
Meat/Protein
Dairy
Sweets/Fats/Oils
Sugary Drinks

Any food allergies?
If yes, please give detail
Any food intolerances
If yes, please give detail
Do you eat a fat-free diet?
If yes, for how long?
Briefly describe your daily fluid intake
(i.e. # of glasses of water, coffee, sugary drinks, alcoholic drinks)
Do you have diabetes?

Yes No
Any Recent Weight Fluctuation?

Yes No
Any vitamin supplements taken?
Type/Quantity/How Often?
Sun Exposure and Genetic History
Tanning ability
General ease of tanning; tan easily/burn easily, etc.
MC1R Gene (Redhead)?
Family genetic history (In regards to sun exposure issues, skin cancer)
Location of Birth and First 25 Years
Sunburn history
Tanning bed use and frequency
Medial History and Medication
Is this your first facial? *

Yes No
If no, when was your last facial?

- Month - Day Year
Are you currently under physicians care for a skin condition? If yes, explain *
What are your main concerns regarding your skin? *
Are you pregnant or nursing? *
Are you now, or have you ever, used any of the following products? *

Azelex Differin Renova Retin A Tazerac Glycolic or Alpha Hydroxy Acids None
Are you now or have you ever used Accutane (If used in the past, when and for how long? *
Are you currently taking any medications (please list) *
Do you have or have you ever had skin cancer. (if yes, enter what kind?) *

No
Please check if you've had any of the following *

Asthma Sinus Problems Hysterectomy Cardiac Problems Pace Maker Chronic Headaches Skin Diagnosis Eczema Anxiety/Depression Immune Disorders Lupus Hepatitis Herpes Fever Blisters Epilepsy High Blood Pressure Metal Bone, Pins, or Joints None
Do you have any allergies to cosmetics, food, or drugs? Please list *
Are you allergic to any of the following? *

Aspirin Iodine Any Essential Oils Roses Pumpkin Papaya Pineapple None
Do you experience claustophobia *

Yes No
Do you use tobacco? *

Yes No
General Skin Care
What skin care products do you use?
Brands/Types
Please list any vitamins you are taking (If none, please type none).. *
How do you feel about your skin at this time (1-10, 10 being best)
Reason for your appointment?
Previous clinical services and frequency
Were your expectations met?
Yes/No, brief explanation
Breifly describe current skincare products, regimen, and which type of skin they are labeled for
Cleanser
Toner
Moisturizer
Night Cream
Eye Cream
Exfoliants
Masks
Sun Protection
Include SPF
Makeup
Confirmation and Cancellations

CONFIRMATIONS

As a courtesy, we will send out an email to confirm your service appointments 24 hours prior to your appointment date. Please ensure that we have your current email address on file in order to be able to do so in a way that may be beneficial to you. It remains your responsibility to remember your appointment dates and times to avoid late arrivals and missed appointments. Less than 24 hours notice will result in loss of service voucher,monthly service or billed for the service.

CANCELLATIONS

Your appointments are very important to us, they are reserved especially for you, we understand that sometimes schedule adjustments are necessary; therefore, we respectfully request at least 24 hours notice for cancellations.

Less than 24hr notice will result in a charge equal to 50% of the reserved service amount.

No shows will be charged 100% of the service amount.

Repeat cancellations will be required to prepay their for their appointments.
Please type your name to acknowledge the confirmation and cancellation policy
Thank you! Enjoy your service!
Should be Empty: