First and last name*

Mobile number*

Email address*

Emergency Contact:*

Emergency Contact's Phone number:*

Any recent surgery, including plastic surgery?*

If yes, please explain:*

Have you ever had irritation after using any skin care product?*

Have you ever had an allergic reaction to Latex*

I understand, have read and completed this 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 esthetician/skin care therapist of my current medical or health conditions and to update this history.*

I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.*