Client Forms

MAKING FACES PATIENT INFORMATION FORM

NAME:_______________________________________________________________DATE:_____________________

ADDRESS:___________________________________________CITY:________________________ZIP:_________________

HOME#__________________________________CELL___________________________WORK#________________________

PREFERRED NUMBER TO CONFIRM H C W

EMAIL:______________________________________________________________________DOB:_______________________AGE________

HOW DID YOU HEAR ABOUT US?__________________________________________________________

ARE YOU PREGNANT?______________________________________LACTATING_____________________

HORMONAL INBALANCES: YES NO IF YES PLEASE EXPLAIN_________________________________________________

HORMONE REPLACEMENT Y N IF YES PLEASE EXPLAIN_____________________________________________________

ORAL CONTRACEPTIVES Y N IF YES WHICH ONE_____________________________________________________________

HOW MUCH WATER DO YOU CONSUME DAILY?________________________________

ARE YOU ON A SPECIAL DIET Y N PLEASE EXPLAIN___________________________________________________________________

DO YOU HAVE EXCESS GAS AND BLOATING Y N PLEASE EXPLAIN_______________________________________________________

HOW MUCH FRUITS AND VEG’S DO YOU CONSUME DAILY?______________________________________________________

HOW MUCH DAIRY DO YOU CONSUME DAILY?___________________________________________________________

HOW MUCH CAFFEINE DO YOU CONSUME DAILY?_______________________________________________________

WHAT IS YOUR STRESS LEVEL? HIGH MODERATE LOW WHAT DO YOU DO TO REDUCE STRESS___________________________

ARE YOU CURRENTLY TAKING ANY MEDICATION AND/OR SUPPLEMENTS? Y N

IF SO PLEASE LIST:_______________________________________________________________________________________________________________

WHAT TYPES OF SKIN CARE PRODUCTS ARE YOU CURRENTLY USING? ____________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________

DO YOU SUFFER FROM BREAKOUTS? Y N

DO YOU BLUSH EASILY? Y N

DO YOU HAVE REGULAR BOWEL MOVEMENTS? Y N

DO YOU EXFOLIATE AT HOME Y N IF YES HOW OFTEN_______________________________________________________________

DO YOU SMOKE? Y N

CLIENT CONTRAINDICATIONS

PACEMAKER Y N

PREGNANCY Y N

CANCER Y N IF YES PLEASE EXPLAIN_________________________________________________________________________

TUMERS Y N IF YES PLEASE EXPLAIN________________________________________________________________________

EPILEPSY Y N

HEART CONDITION Y N PLEASE EXPLAIN______________________________________________________________________

HIGH BLOOD PRESSURE Y N

DIABETES Y N

AUTOIMMUNE DISORDER Y N PLEASE EXPLAIN_________________________________________________________________

MULTIPLE SCLEROSIS Y N

VARICOSE VEINS Y N

CLAUSTROPHOBIC Y N

DEVELOP COLD SORE Y N LAST OUTBREAK__________________________________________________

LACK OF NORMAL SKIN SENSATION Y N PLEASE EXPLAIN_________________________________________________________

SKIN CANCER OR DISEASE Y N PLEASE EXPLAIN__________________________________________________________________________

THROMBOSIS/PHLEBITIS Y N

METAL IMPLANTS/PLATESE OR SCREWS Y N PLEASE EXPLAIN __________________________________________________________________________________________________

BOTOX Y N THE LAST TIME_________________________________________________________________________________________________

INJECTIONS/FILLERS Y N THE LAST TIME_______________________________________________________________________________

DO YOU USE ACCUTANE? ________RETIN A OR RETINOLS________________AHA’S__________TAZORAC______DIFFERIN________

ANY OTHER TOPICAL MEDICATIONS THAT ARE NOT LISTED ________________________________________________________________________________________________________________________________

DO YOU HAVE ANY ALLERGIES? SEASONAL - TOPICAL - INTERNAL PLEASE LIST: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

HAVE YOU EVER USED A PRODUCT THAT HAD GIVEN YOU A BAD REACTION? Y N EXPLAIN:

________________________________________________________________________________________________________________

SKIN REJUVENTATION INFO

SKIN CONCERNS PLEASE CIRCLE ALL THAT APPLIES

FINE LINES AND WRINKLES - FACIAL FOLDS AROUND MOUTH AND NOSE - ROUGH TEXURE – ACNE

DRY SKIN – SAGGIN SKIN – TIRED LOOKING SKIN – UNEVEN SKIN TONE - BROWN SPOTS – FACIAL REDDNESS

DARK CIRCLES UNDER EYES – PUFFINESS UNDER EYES - SCARRING – BLACKHEADS /CLOGGING – CELLULITE

LOSE BODY SKIN- UNWANTED FACIAL HAIR - BODY ACNE - AGING HANDS - AGING DECOLLTAGE

SUNDAMAGE ON BODY – NECK LAXITY – EXCESS OIL

WHAT ARE YOUR TOP 5 CONCERNS

1. _________________________________________________________________________________________________________

2.__________________________________________________________________________________________________________

3.__________________________________________________________________________________________________________

4._____________________________________________________________________________________________________________

5._______________________________________________________________________________________________________________

WHEN WAS YOUR LAST FACIAL?_______________________________

WHAT TYPE OF TREATMENT WOULD YOU PREFER TODAY?___________________________________________________________

PLEASE CIRCLE ANY OF FOLOWING THAT YOU HAVE HAD IN THE PAST 5 YEARS

ACCUTANE BOTOX MICRODERM CHEMICAL PEELS LASER RESURFACING LASER PEELS LASER HAIR REMOVAL INJECTIONS/FILLERS RETIN A HYDROQUINONE(SKIN LIGHTNER) LED LIGHT FACIAL SURGERY

DO YOU TAN Y N INDOOR OUTDOOR BOTH LAST TIME______________________________________________________________

DO YOU WEAR SUNSCREEN EVERYDAY? Y N ONLY WHEN ITS SUNNY

DO YOU USE ANY PRODUCTS WITH AHA ACIDS? GLYCOLIC LACTIC SALICYLIC MALIC

IT MAY BE NECESSARY TO RECOMMEND HOME SKIN CARE REGIME TO ACHIEVE THESE RESULTS WILL THAT BE OKAY FOR YOU Y N IF NO WHY NOT?________________________________________________________________________________________

WOULD YOU LIKE US TO EMAIL OUR MONTHLY SPECIALS, DISCOUNTS, AND EVENTS Y N

CONSENT AND AGREEMENT

I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT AND THAT I HAVE BEEN DULLY ADVISED BY MAKING FACES LLC CONCERNING THE NATURE OF THE TREATMENT PROCESS TO BE ADMINISTERED BY THE AESTHETICIAN. I REALIZE THAT THIS IS NOT A SUBSTITUTE FOR MEDICAL CARE, AND THAT INDIVIDUAL RESULTS ARE DEPENDENT OF MY SKIN HEALTH, CONDITION, AGE AND LIFESTYLE.

I UNDERSTAND TO ACHIEVE THE MOST OPTIMAL RESULTS I WILL NEED TO BE COMMITTED TO USING THE APPROPRIATE SKIN CARE MY ASETHETICIAN ADVISES. I AM ALSO AWARE THAT TREATMENTS SHOULD BE SCHEDULED ANYWHERE FROM 1 WEEK TO 5 WEEKS APART TO ACHIEVE OPTIMAL RESULTS. THE AESTHETICIAN RESERVES THE RIGHT TO REFUSE ANY SERVICE FOR THE REASONS OF THE SAFETY TO THE PATIENTS HEALTH OF THE SKIN.

MY SIGNATURE BELOW RELEASES THE AESTHETICIAN, BUSINESS NAME AND STAFF HARMLESS AGAINST ANY LIABILITY THAT MAY INCUR FROM THE TREATMENT. I WILL AGREE TO KEEP MY AESTHETICIAN INFORMED OF ANY CHANGES IN MY PATIENT HISTORY AND FAILURE TO DO SO WILL RELEASE MY AESTHETICIAN OF ANY LIABILITY.

SIGN________________________________________________________PRINT__________________________________________________DATE____________ UNDER 18 PARENT MUST SIGN_______________________________________________________________________________DATE_________________

CANCELLATION POLICY:

WE REQUIRE A FULL 24 HOUR CANCELLATION NOTICE BY PHONE SHOULD YOU NEED TO CANCEL OR RESCHEDULE YOUR APPOINTMENT. FAILURE TO DO SO WILL RESULT IN A CHARGE OF 100% OF THE SCHEDULED TREATMENT PRICE.

IF YOU ARE 20 MINS + LATE YOU WILL BE CONSIDERED A NO SHOW AND CHARGED 100% OF THE TREATMENT SCHEDULED.

IF YOU ARE UP TO 15 MINUTES LATE WE WILL DEDUCT THAT TIME FROM YOUR SCHEDULED SERVICE.

GIFT CERTIFICATES USED FOR THE APPOINTMENT WILL BE FORFEITED IF APPOINMENT IS MISSED OR CANCELLED WITHOUT A 24 HOUR NOTICE.

IF THERE IS AN EMERGENCY IT WILL BE AT THE DISCRETION OF MANAGEMENT WHETHER OR NOT THE FEE SHALL BE WAIVED.

I HAVE READ THIS POLICY AND FULLY UNDERSTAND AND AGREE TO IT ENTIRELY,

SIGN AND DATE______________________________________________________________________DATE__________________________

PHOTO CONSENT

SOME TREATMENTS THE AESTHETICIAN MAY WANT TO HAVE BEFORE AND AFTER PHOTOS TAKEN WOULD YOU CONSENT TO THIS?

IF YES PLEASE SIGN AND DATE___________________________________________________DATE___________________________________________