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Name: <CLIENTFIRSTNAME> <CLIENTLASTNAME> Date of Birth: <CLIENTBIRTHDATE>
Address: <CLIENTADDRESS> <CLIENTCITY> <CLIENTSTATE> <CLIENTPOSTCODE>
E-mail Address: <CLIENTEMAIL> Phone: <CLIENTPHONE>
How would you like us to contact you?
Email Text Mail Phone
How did you hear about Facials by Bonnie?
What are your main skin concerns? (Check all that apply)
Acne
Blemishes
Oiliness
Brown Spots/Sun spots
Clogged pores/blackheads
Loss of tone/lack of firmness
Redness/sensitivity
Rosacea
Easily irritated by products
Dehydration (tightness)
Dryness (tightness/flakiness)
Lines and wrinkles
Large pores
Age prevention
Other:
*Are you presently under a physician’s care for any current skin condition or other problem?
Yes No
If Yes, please elaborate:
*Are you currently taking medications or dietary supplements?
Yes No
If "Yes" please list:
*Do you have any allergies to cosmetics, food or drugs?
<INDEX(9),M>
If "Yes" please list:
<HEALTHISSUES(40,700)>
*Do you have an open sore such as cold sore, dermatitis?
Yes No
If "Yes" please list:
*Are you effected by or have any of the following:
<INDEX(10),M>
Asthma
Cardiac Problems
Eczema/Psoriasis
Hepatitis Simplex
Herpes
High blood pressure
H.I.V.
Pacemaker
Thyroid Problems
PCOS
Cold Sores
*Have you ever used the following?
Accutaine
Retin A
Tazorac
None
Other:
If "Yes" when and for how long?
At what age did you start to breakout?
*When you get breatkouts, do you mostly get inflamed, cystic pimples or small little bumps under the skin?
Mostly inflamed
Mostly non-inflamed (lots of small bumps)
combination of both inflamed and non-inflamed
*How often do you get new pimples?
Mostly before or during menstrual cycle
Every once in a while
On what part of face is acne located? Check all that apply!
Forehead Cheeks Chin Hairline Nose Jaw Line Neck
FEMALE CLIENTS:
Are you pregnant?
Yes No
Are you taking oral contraception?
Yes No
Are you on Hormone Replacement?
Yes No
Do you have a regular menstrual cycle?
Yes No
If "No" please elaborate:
MALE CLIENTS:
What is your current shaving system?
Wet Electric
Do you experience irritation from shaving?
Yes No
Do you experience ingrown hair?
Yes No
WHAT IS YOUR CURRENT SKIN CARE ROUTINE
*Do you use Cleanser?
Yes No
If yes, which one and how often:
*Do you use Toner?
Yes No
*Do you use Moisturizer?
Yes No
If yes, which one and how often:
*Do you use Serums?
Yes No
If yes, which one and how often:
*Do you use Scrubs?
Yes No
If yes, which one and how often:
*Do you use Masks?
Yes No
If yes, which one and how often:
*Do you use Sunscreen?
Yes No
If yes, which one and how often:
*Do you use any other products?
Yes No
If yes, which one(s) and how often:
I understand that it is imperative to my health that I disclose all of the information requested in the Client Profile/Health History.
<MANFIELD(20,60)> Initials
I consent to the taking “before and after” photographs for the purpose of documentation, potential advertising and promotional purposes.
<MANFIELD(20,60)> Initials
After completing this questionnaire make sure to email us photos of your face.
When taking photos of your face please take one left side shot, one right side shot and one headshot. Please email the photos tofacialsbybonnie@gmail.com with the subject Acne photos and your name.
Acne Treatment Consent Form
IMPORTANT: PLEASE READ CAREFULLY and initial
<MANFIELD(20,65)> I have not been exposed to excessive sun and my skin does not feel sensitive or irritated in any way.
<MANFIELD(20,65)> I have not had any other chemical peel of any kind, within 14 days of this treatment.
<MANFIELD(20,65)> I have not had any facial waxing, within seven days of this treatment.
<MANFIELD(20,65)> I have informed the clinic of all health problems of which I am aware, including herpes simplex/cold sores.
<MANFIELD(20,65)> I have informed the clinic of any use of oral or topical medications I may be using including Retinoids (Retin-A, Renova, Avita, Differin, Tazorac) or Accutane.
<MANFIELD(20,65)> I understand that controlling acne/problem skin is best achieved through a series of recommended treatments and compliance to the home care product program recommended by Facials by Bonnie.
<MANFIELD(20,65)> I understand that I will probably not experience much visible peeling, flaking, discoloration or irritation following this procedure if I follow my homecare instructions carefully.
WARNINGS: PLEASE READ CAREFULLY and initial
<MANFIELD(20,65)> Avoid direct sunlight or tanning booths for at least three days following a treatment.
<MANFIELD(20,65)> Use of sunblock protection is necessary following all treatments.
<MANFIELD(20,65)> Do not pick your skin following a treatment.
<MANFIELD(20,65)> Some of the products recommended by Facials by Bonnie are clinical-strength active formulas designed to treat problem skin conditions. Tingling sensations are normal with product application but should not be painful. If you are experiencing stinging and irritation with any product, stop using the product and call your esthetician for further instruction.
<MANFIELD(20,65)> Cancellation Policy:
We are proud to offer a professional service offering the highest quality of care possible. In order to uphold this standard, we adhere to a 24-hour cancellation policy. For short-notice (less than 24 hours) cancellations or missed appointments, you will be charged the full appointment fee. Should you need to cancel or reschedule your appointment, please notify Facials by Bonnie 24 hours in advance to avoid the charge.
I hereby agree to all of the above and agree to have this treatment be performed on me. I further agree to follow all post-treatment care instructions as I am directed.
I hereby release Facials by Bonnie from any liability connected with the services provided to me. (Must be signed by parent/guardian for clients under the age of 18)
Client or Parent/Guardian Signature (in case of a minor) Below:
