Aesthetic TREATMENT CLIENT DATA FORM PAGE 1 of 2. Date of last aesthetic treatment: _____________________________________________. Have you ever undergone radiotherapy or chemotherapy? YES NO have you ever used Accutane in the last six months?
Aesthetic TREATMENT CLIENT DATA FORM PAGE 1 of 2. Date of last aesthetic treatment: _____________________________________________. Have you ever undergone radiotherapy or chemotherapy? YES NO have you ever used Accutane in the last six months?
Direitos autorais:
Attribution Non-Commercial (BY-NC)
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Baixe no formato PDF, TXT ou leia online no Scribd
Aesthetic TREATMENT CLIENT DATA FORM PAGE 1 of 2. Date of last aesthetic treatment: _____________________________________________. Have you ever undergone radiotherapy or chemotherapy? YES NO have you ever used Accutane in the last six months?
Direitos autorais:
Attribution Non-Commercial (BY-NC)
Formatos disponíveis
Baixe no formato PDF, TXT ou leia online no Scribd
How did you hear about us: ___________________________________________________
Would you like to be informed of upcoming promotions via email? YES NO
1.) Date of last aesthetic treatment: ____________________________________________
2.) What are your treatment objectives? (i.e. relaxation, healthy skin, etc.) ___________________________________________________________________________ 3.) Are you presently under the care of a doctor or dermatologist? YES NO If yes, please explain: ___________________________________________________ 4.) Have you undergone facial surgery in the last 9 months? YES NO If yes, please explain: ___________________________________________________ 5.) Have you ever undergone radiotherapy or chemotherapy? YES NO 6.) Are you epileptic? YES NO 7.) Do you smoke? YES NO 8.) Are you on topical prescription medications? (Retin-A, Differin, Tazorac) YES NO If yes, please list: _______________________________________________ 9.) Have you used Accutane in the last six months? YES NO 10.) Have you undergone any of the following treatments: Laser, medical dermabrasion, or chemical peeling? YES NO If yes, please list dates: __________________________________________________ 11.) Do you wear contact lenses? YES NO 12.) Any skin sensitivities we should acknowledge? YES NO If yes, please explain: ____________________________________________________ 13.) Please list any known allegies: ______________________________________________
Female clients only:
Are you pregnant or trying to become pregnant? YES NO Are you lactating? YES NO Are you menopausal? YES NO Do you have increased hormonal activity? YES NO
Male clients only:
Have you ever experienced irritation from shaving? YES NO Do you have ingrown hair? YES NO
4703 West Lovers Lane, Dallas 75209 (214) 352-8800 www.luxuryonlovers.com
AESTHETIC TREATMENT CLIENT DATA FORM PAGE 2 OF 2
Do you have any of the following conditions:
Herpes YES NO Hepatitis B YES NO Hepatitis C YES NO H.I.V. YES NO Rosacea YES NO Claustrophobia YES NO Edema YES NO Varicose veins YES NO
I, the undersigned, recognize the importance of accuracy of the information
provided to facilitate the most effective treatment protocols. Consequently, I confirm this information to be exact.