Your Skin Journey

New Client Privacy Notice:

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and avoid possible skin reactions.
Whats your name? *

First Last
E-mail *
We will never give or sell your email to a third party.
Phone *

Area Code Phone Number
What type of consultation would you like? *

In person with first treatment Phone Call Facetime Google Meets
How did you hear about Skin Clinical SF? *

Do you smoke or chew tobacco products everyday? *

Yes No
Smoking greatly reduces healing of the skin and will effect the outcome of your treatments. It is best to avoid smoking 24-48 hours before and after your treatment.
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
I understand that I must discontinue use of ALL of the above 5 days prior to treatment. Accutane or Isotretinoin must be discontinued 1 year prior to treatment.

YES, I will discontinue.
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated? *

Yes No
If yes, please explain:

Preparing for your consultation
- Please fill in all your products below. This will allow us to research prior to your consultation.
- After you submit this form you'll be directed to book your first appointment.
- Once you purchase products, a personalized PDF regimen will be emailed to you, containing easy to follow, detailed instructions. Your personalized regimen is designed to strengthen and correct; while working to prepare your skin for professional treatments in the clinic or at home.
Current skin care products you use at home. Include brand names and product names. Each product will be researched and evaluated for use moving forward. Some products may be discarded if they do not support your skin properly.
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. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Skin Clinical and/or the skin care professional from liability and assume full responsibility thereof. *

I understand the cancellation policy.
OPTIONAL: If before and after photos are taken, I grant permission to Skin Clinical SF, Inc. to use my photos for marketing purposes on www.skinclinicalsf.com or other business listing pages such as Instagram.

I grant permission.
Date *

Month Day Year
Signature *
Should be Empty:

New Client Privacy Notice:

Female Clients

Skin Care History