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19 Danbury rd, Ridgefield CT

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Home
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About
Contacts
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Client form

Client form

Fill out this client form.

First Name *

Last Name *

Date of birth *

Age *

Gender *

Postal code *

Phone *

Email *

Address *

City *

How would you consider your skin?

What are the changes you'd most like to see in your skin?

Are you pregnant or nursing?

YES
NO
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Do you have any allergies?

How did you know about ut?

FG/Insta AD
Google
Friend
Other
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Please mark any of the conditions you may currently have

Acne

Glaucoma

Autoimmune disorders

Heart disease

Cold sores of fever blisters

High blood pressure

COPD

Hepatitis B or C

Cancer

Herpes simplex

Diabetes

Hemophilia

Dermatitis

HIV/AIDS

Keloids or hypetrophic scars

Eczema

Epilepsy

Migraines

Psoriasis

Rosacea

Seborrheic infection

Tinea

Urticaria

Warts

Other

What are your main concerns?

Acne, Breakouts

Sun damage

Blackheads

Age spots

Dry skin

Melasma

Oily skin

Scars

Dull skin

Keratosis pilariss

Dehydrated skin

Ingrown hairs

Razor burn

Dark circles under the eyes

Rosacera

Hyperpigmentation

Eczema

Enlarged pores

Skin redness

Under-eye puffiness

Uneven skin tone

Premature aging

Psoriasis

Whitebeads

Excessive facial hair

What is you skin type?

Normal skin

Dry skin

Oily skin

Combination skin

What is your skin condition?

Sensitive skin

Acne-prone skin

Aging skin

Dehydrated skin

Rosacea-prone skin

Sun-damaged skin

Hyper pigmented skin

Psoriasis-prone skin

What is your skin routine?

Foam cleanser

Moisturiser

Gel cleanser

Eye cream

Makeup remover

Sunscreen

Toner

Face mask

Exfoliant

Serum

Spot treatment

Facial oil

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

Cosmetics

Sunscreen

Essential oils

Shellfish

Medication, lodine

Nuts

Latex

Food

Pollen

Alpha hydroxy acids

Aspirin

Animals

Skin products

Fragnance

Other

If yes to any of the above, please explain here more

Are you taking any medications, vitamins, including over-the-counter or prescription drug?

Yes

No

Have you ever experienced Botox, Restylane or Collagen injections?

Yes

No

If yes, when was it done? (Botox, Restylane... Question)

Within the last nine months, have you undergone any surgery or plastic surgery?

Yes

No

Are you currently using any products that contain the following ingredients? (Glycolic acid, Acetic acid, exfoliatng crub - any, hydroxy acid product, Vitamin A derivaties - E.g. retinol, Renova)

Yes

No

If yes, please put the name (Products with specific ingredients question)

Are you taking birth control?

Yes

No

Have you used or been prescribed any medications (topical or oral) for ance / ance control?

Yes

No

Have you recently received any of the following treatment?

Microdermabrasion

Chemical Peel

Lash tint

Brow tint

Micro needling

Facial waxing

None of these

Are you undergoing any hormone replacement therapy?

Yes

No

What are your expectations and goals for the treatment?

Can we record videos/take photos of you and the process for social media/advertising?

Yes

No

Date Picker

Client Signature

I agree to the terms & conditions and by submitting I also agree to reading this client consent.

21

Services

900

Procedures

99

% Happy clients

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19 Danbury Rd, Ridgefield, CT 06877, Spojené státy americké

19 Danbury rd, Ridgefield CT

[email protected]

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