Today's Date *

Full Name *

Date of birth *

Age *

Address *

City *

State *

Postal code *

Phone *

By providing my phone number, I agree to receive text messages from the business.

Email *

Any known skin allergies? *

Yes

If yes to skin allergies, please list below: *

Medications

Anti-Coagulants
Anti-Hypertension
Hormones
Thyroid
Aspirin
Multivitamins
Radiation Therapy
Chemotherapy

Other Medications

Smoker? *

Wear Contacts? *

Do you follow a restricted diet?

Daily water consumption? (in ounces)

Daily alcohol consumption? (in ounces)

Daily caffeine consumption? (in ounces)

Currently under the care of physician or dermatologist?

If yes, under care of physician or dermatologist, please explain:

Any surgeries in the last 6 months?

If any surgeries in last 6 months, please explain:

Any dermal injections/fillers in the last 6 months?

If any dermal injections/fillers in last 6 months, please explain:

Are you currently using, or have used in the last 3 months, any products that contain Retin -A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product?

If you have used any products that contain Retin -A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product, please explain:

Client Consent

I understand, have read and completed the questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential. The treatments I receive here are voluntary and I release and from any liability and assume full responsibility thereof.

Signature *

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Hair Rejuvenation Center