Lotus natural health & beauty

LOTUS NATURAL HEALTH & BEAUTY
CLIENT SKIN CARE PROFILE
Please answer all questions to the best of your ability. Please print clearly. Thank you. Name _______________________________________Date _______ Street Address___________________________________________ City______________________ State___________Zip____________ Home #_____________Cell#_____________Work #_____________ Email Address_____________________________________________ Date of Birth________________Age___________________________ Occupation_________________________Referred by______________ Are you currently or in the last year under any doctor’s care? Y___N_____ Explain ______________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ Have you undergone surgery recently? Y______N______ Do you have any health problems/issues? Diabetes ___ Thyroid ___ List any medications, supplements that you are currently taking: Do you have metal implants or a pacemaker? ___________ Do you have any specific skin care problems/allergies pertaining to your face or body? Please list. __________________________________________________ What skin care products do you currently use? ______________________ Do you use Retin A – Renova - other? Y __ N __ _____________________________ Have you ever had chemical peels, microdermabrasion or any resurfacing treatments? Y ___ N ___ In the last month? Y __ N__ Have you had filler (Juvederm, Radiesse, etc) or Botox? Last date_____ Do you smoke? __________ Do you exercise regularly? ____________Do you wear contacts? _____________ Do you sunbathe or use tanning beds? Y __ N __ Do you use sun block/screen? Y __ N __
Do you burn easily? __________________________
What are your skin care goals? _________________________________
If I experience any pain or discomfort during the session, I will immediately inform the
esthetician so that the products or technique may be adjusted to my level of comfort. I
further understand that a treatment should not be construed as a substitute for medical
examination, diagnosis, or treatment. I understand that estheticians are not qualified to
perform, diagnose, prescribe or treat any physical or mental illness and that nothing said in
the course of the session given should be construed as such. I affirm that I have stated all
my known medical conditions and answered all questions honesty. I agree to keep the
esthetician updated as to any changes in my medical profile and understand that there shall
be no liability on the estheticians part should I fail to do so. I acknowledge that the
possibility of an adverse reaction to any sessions including (facial, waxing, sugaring, peels,
use of any machines, or product) can occur and that this is the case regardless of
precautions taken. I accept sole responsibility for the treatments I receive and for any
medical care that may become necessary. I will immediately contact the Esthetician who
performed the treatment of any adverse reactions. In the event that I cannot reach such
person I will immediately seek medical care. The Esthetician has informed me of and
answered all of my questions concerning the treatment (s). I clearly understand the above
information. I clearly understand that Lotus Natural Health & Beauty and its agents may
refuse to perform treatments if I have answered “yes” verbally or on the intake form. I
understand I have given up rights by signing this release and that it represents an
agreement between Lotus Natural Health & Beauty and me. I agree that my participation in
any treatment is voluntary and I accept the inherent risks. I hereby release Lotus Natural
Health & Beauty, its agents, owners, employees, successors and assigns, and suppliers from
any and all damage or injury that may result from the treatment I receive. I represent
that all information provided by me is true and correct. I am over the age of 18 years old.
I hereby authorize the therapist to perform said services/treatments.
Client Name (please print) ____________________________________
Client Signature __________________________________ Date ______
Esthetician ______________________________________Date ______
Consent for treatment of Minor

By my signature below, I hereby authorize a State Licensed Esthetician at Lotus Natural Health & Beauty to
administer a facial treatment to my child or dependent, as they deem necessary.
Guardian Name (please print) __________________________Date _____
Guardian Signature _________________________________ Date ____

Source: http://www.lotusbaby.net/wp-content/uploads/2012/11/Client-questionare.pdf