Skin Care Release Form

Skin Care Form

Please fill out the fields below in their entirety and submit prior to your appointment. Thank you.

Date of Appointment*
Date Format: MM slash DD slash YYYY
Client Name*
First Last
Cell Phone*
Alternate Phone
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Date Format: MM slash DD slash YYYY
Occupation*
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Have you seen a doctor in the past year for a skin disorder?*
If yes, describe/explain
Are you experiencing any skin conditions now?*
If yes, describe/explain
Are you currently under a doctor's care?*
If yes, list diagnosed conditions
Are you currently taking any prescription medications?*
If yes, please list
Have you ever used Retin A?*
If yes, when & how long?
Have you ever used Accutane*
If yes, when & how long?
Have you ever used Benzoyl Peroxide*
If yes, when & how long?
Have you ever used Glycolic Acid/AHA's*
If yes, when & how long?
Are you currently taking any hormones
If yes, what kind?
Are you currently taking any vitamins*
If yes, what kind?
Have you ever undergone any cosmetic surgery or had dermabrasion?*
If yes, when and what area of your face/neck?
Are you pregnant?*
What is Your Due Date?
Date Format: MM slash DD slash YYYY
Do you have any allergies*
If yes, please list
Have you used dermal fillers?*
If yes, when and what area of your face?
Do you consume alcohol?
If yes, how much?
Please describe any specific areas or issues you'd like your esthetician to focus on?*
Would you like suggestions for at home care product to address anti-aging, decongest pores or general hydration?*
E Signature*
By E signing below, I confirm that I have stated all known medical conditions and have consulted a medical doctor for stated conditions. I hereby release Jinsei Spa, its staff and Licensed Estheticians of any and all liability past, present and future.
First Last
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.