Esthetician - The Body Studio Treatment Form

The patient receiving services from an Esthetician at The Body Studio, LLC (or the Guardian of the patient) must complete the following information before the first treatment session.

Patient Name

First NameLast Name

Date of Birth

For Patient

Date of Birth

For Patient

Mobile Number

Area CodePhone Number

Other Number (optional)

Area CodePhone Number

Physical Address

Street Address

CityState / Province

Postal / Zip Code

Email

We may send you special deals from time to time by e-mail which you will be able to opt-out of at anytime.

How did you hear about us?

Who referred you?

If other, please specify:

Do you have a coupon? If so, please enter the coupon code or description:

Text Body2019 to 555-888 for Exclusive Coupons

YOUR HEALTH:

Within the last year, have you been under a dermatologist's or other physician's care?

If yes, please specify:

Leave blank if you answered NO to the last question.

Have you had any health problems in the past or present?

If yes, please specify:

Leave blank if you answered NO to the last question.

Are you taking any medications, supplements, vitamins, diuretics, slimming pills, lostretinon, etc. that you take regularly?

If YES, please list all:

Leave blank if you answered NO to the last question.

Check YES or NO on the following questions:

Rows	YES	NO
Do you smoke?
Do you exercise regularly?
Do you follow a restricted diet?
Do you wear contact lenses?
Do you have metal implants, a pacemaker or body piercings?

Rate your level of stress on a scale of 1 to 5 (1 being low and 5 being high)

Do you have any allergies? Latex, nickel, etc.

If YES, please specify:

Leave blank if you answered NO to the last question.

Check YES or NO on the following questions:

Rows	YES	NO
Have you ever had an allergic reaction to Aspirin?
Do you sunbathe or use tanning beds?
Do you drink more than 4 caffeinated beverages daily?
Have you ever experienced claustrophobia?

YOUR SKIN:

What are your specific concerns or challenges with your skin?

What skin care products are you currently using?

Rows	YES	NO
Face Soap
Face Cleanser
Face Toner
Face Moisturizer
Masque
Exfoliator
Eye Products
Serums
Body Soap
Shower Gel
Scrubs
Oil
Body Moisturizer
Depilatory Products
Self Tanners

Check YES or NO on the following questions:

Rows	YES	NO
Have you had a chemical peel, microdermabrasion, Laser or Light Therapy, an injectable, or other cosmetic procedure in the last month?
Have you waxed within the last 72 hours?
Do you use Retin-A Renova, Adapalene, or any other prescription skin products in the last 3 months?
Have you taken isotretinoin (accutane) within the last 6 - 12 months?
Do you have metal implants, a pacemaker or body piercings?

Are you currently using any products that contain the following ingredients?

Rows	YES	NO
Glycolic Acid
Lactic Acid
Any Exfoliating Scrubs
Any Hydroxy Acid Products
Vitamin A Derivatives (i.e. Retinol)

Do you ever experience these conditions on your skin?

What SPF Sunscreen do you use on your face?

What SPF Sunscreen do you use on your body?

Check YES or NO on the following questions:

Rows	YES	NO
Do you burn easily in moderate sunlight?
Have you had any direct sun exposure within the last 48 hours?
Do you have a tendency to redness?
Do you suffer from sinus problems?
Are you prone to cold sores or fever blisters?
Are you currently experiencing a breakout
Do you ever experience burning, itching or stinging sensations on your skin?

Do you ever experience burning, itching or stinging on your skin?

If yes, please specify:

Your Gender:

FEMALE ONLY CLIENTS:

Check YES or NO on the following questions:

Rows	YES	NO
Are you taking oral contraception?
Are you pregnant or trying to become pregnant?
Are you lactating?
Are you currently having or due for your menstrual period?

MALE ONLY CLIENTS:

Do you have any shaving challenges?

If YES, please specify:

Leave blank if you answered NO to the last question.

QUESTIONS TO DISCUSS EACH VISIT:

Have you started any new medication since your last visit?

What are your expectations with this treatment?

Optional

CONSIDERING OTHER SERVICES?

What areas have you considered treatment for today or in the future?

I authorize the staff and members of The Body Studio, LLC to perform the following laser treatment procedures: Hair removal, skin rejuvenation, pigmentation reduction, veins/rosacea treatments, tattoo/scar removal treatments, acne/acne scar treatments and/or red blood vessel reduction, Spa Facials, Massage Therapy and Laser Teeth Whitening.

I understand that multiple treatment sessions may be necessary to achieve satisfactory results and that the results can vary according to skin type, hair type as well as your medical condition.

I agree to allow The Body Studio, LLC to use photographs of the treated areas for documenting and monitoring of the treatment progress only.

By signing this form (The Body Studio, LLC Esthetician Consent for Treatment) you and anyone claiming on your behalf can not hold The Body Studio, LLC, its affiliates, successors and assigns, officers, employees, representatives, partners and agents liable for past injuries, future injuries or damages of any kind.

Patient Name:

First NameLast Name

Guardian Name (if applicable):

First NameLast Name

Date you completed this form:

Date

Date you completed this form:

Date

Patient or Guardian Signature (use your finger or iPen)

If you’re the legal guardian of the patient receiving services from The Body Studio, LLC, you’re agreeing in its entirety to The Body Studio, LLC Consent for Treatment form on the patients behalf.

The Body Studio, LLC Esthetician Treatment Form

The Body Studio, LLC Esthetician Consent for Treatment