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AESTHETIC TREATMENT

CLIENT DATA FORM


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Date: _______________ Birthday (Day/Month) ___ / ___


Name: _______________________________________________________________________
Address: ___________________________ City/State: ________________ Zip: __________
Primary Phone: _________________ Secondary Phone: ___________________________
Email: _________________________________________________________________________

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
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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.

Client’s Signature _________________________________ Aesthetician’s Initials_______

Client Notes (Aesthetician use only):

4703 West Lovers Lane, Dallas 75209 (214) 352-8800 www.luxuryonlovers.com