Client Consult Form Fields marked with an * are required. Name* First Last Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Email* Birth Month*SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberHow did you hear about Pure Aesthetics?*SelectWord of mouthInternetPhone bookNewspaperOtherI heard about Pure Aesthetics via: General Health Record1. Do you have any heart problems?* Yes No 2. Do you have any sinus problems?* Yes No 3. Do you have any shoulder injuries?* Yes No 4. Do you smoke?* Yes No 5. Do you use tanning beds?* Yes No 6. Do you use Accutane?* Yes No 7. Do you use products containing glycolic acid?* Yes No 8. Have you ever had an acid peel?* Yes No 9. Are you using a harsh exfoliator?* Yes No 10. Do you use products containing alcohol?* Yes No 11. Are you on the pill?* Yes No Since when on the pill? MM slash DD slash YYYY 12. Are you pregnant or lactating?* Yes No 13. Do you have any menopausal problems?* Yes No 14. Are you taking any hormones?* Yes No 15. Do you feel nervous tension?* Yes No 16. Do you have trouble sleeping?* Yes No 17. Do you use Retin A?* Yes No I use Retin A for: Acne Cosmetics Other Please describe what you use Retin A for 18. Are you claustrophobic?* Yes No 19. Are you asthmatic?* Yes No 20. Are you epileptic?* Yes No 21. Are you diabetic?* Yes No 22. Do you have hemophilia?* Yes No 23. Do you have arthritis?* Yes No 24. Do you have hepatitis?* Yes No 25. Do you have a pacemaker?* Yes No 26. Do you have any skin problems?* Yes No Please explain your skin problems: 27. Do you have any allergies?* Yes No Please list any allergies: 28. Do you have any skin cancer?* Yes No Where is the skin cancer? 29. Have you had any recent surgeries?* Yes No Please explain any recent surgeries: 30. Are you taking any medication (OTC or prescription)* Yes No Please list any medication: 31. Do you follow any special diet?* Yes No Please explain any special diet: 32. Are you undergoing any homeopathic treatments?* Yes No Please explain any homeopathic treatment: General Skincare Information1. How do you cleanse your face? (specify brand)* 2. Do you find that your skin is shiny throughout the day?* Yes No 3. Do you use any home treatment products?* Yes No Please specify what brand of home treatment products: 4. Do you feel any burning or itching of the skin?* Yes No Please specify area of burning or itching: 5. Have you ever had a facial before?* Yes No When was your last treatment? MM slash DD slash YYYY 6. What is the purpose of your visit?* 7. What improvements would you like to see in your skin?* Signature* All services are performed by students under the supervision of a licensed instructor. By signing this waiver, I understand that under certain circumstances due to the condition of my skin, the products and equipment used at Pure Aesthetics Skincare School – considered generally safe and commonly used in spa settings – could cause damage. I nevertheless agree to waive and hold harmless Pure Aesthetics Skincare School, its administration, instructors, and students, from any claims arising from the services performed.NameThis field is for validation purposes and should be left unchanged. 2956
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