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Confidential Consultation form

Personal Information Today's Date: _________________ Name: ________________________________________________________________ Sex: Male Female Last First M.I. Address: _______________________________________________________ Date of Birth: ______________ City: __________________________________________________ State: ________ Zip: ________________ Phone Numbers: _____________________ _____________________ _____________________ Home Work Mobile EMail: ______________________________________________ Occupation: ___________________________ Emergency Contact: _______________________________________________ Phone: ____________________ Whom may we thank for referring you? ___________________________________________________________ Goals for session What are your longterm skin care goals? ________________________________________________________________ What are your areas of concern? _______________________________________________________________________ What are your goals for this treatment? _________________________________________________________________ Personal Skin Care History Please check () current products you use: ___ Eye makeup remover ___ Skin freshener (Toner, Astringent) ___Eye cream ___ Facial scrub ___ Body lotion/cream ___ Sunscreen # __________ ___ Cleansing cream/lotion ___ Day cream ___ Neck cream ___ Exfoliants ___ Body scrub ___ Facial soap ___ Night cream ___ Mask ___ Body soap ___Hand cream ___ Other: ________________________________________________________ Have you ever had a facial treatment? _____ If yes, where and when? ________________________________________ Was it a beneficial experience? ________________________________________________________________________ Have you ever had a body/bust treatment? ______________________________________________________________ How much time do you spend on your daily skin care/makeup routine ________________________________________ Do you tend to tan or burn? ________________ Do you exercise? How much? ____________________________ Do you smoke? _______ How much sleep do you get per night? ________________________________________ How much do you drink of the following: None Little Moderate Heavy Water ___ ___ ___ ___ Coffee ___ ___ ___ ___ Tea (green or black) ___ ___ ___ ___ Alcohol ___ ___ ___ ___ Soft Drinks ___ ___ ___ ___ Have there been any activities or products that aggravate your skin? ________________________________________

Healthy Living Spa 611 East Hawkins Parkway, Longview, TX 75605, Spa (903) 3236510 * Fax (903) 3236520 www.GSMCInstitute.org

Confidential Consultation Form (pg2) Clients name: _______________________________________________

Medical History

___ Accutane ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Acne Allergies Arthritis ___________________ Artificial implants Asthma Birth control ________________ Blood disorder Blood thinner Cancer claustrophobia Contact lens Depression Diabetic

Last

First

M.I.

Please check () where applicable with details.

___ Distended capillaries ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Eczema Epilepsy Fever blisters Heart condition Hepatitis High blood pressure HIV/AIDS Hyper/Hypo pigmentation Hyper/Hypo thyroid Insomnia Lupus Metal plates or pins Nail disorders ___ Pacemaker ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Phlebitis Plastic surgery Pregnant Psoriasis RetinA TM Scleroderma Seborrhea Sensitivities Skin Cancer _______________ Surgeries Underweight/ Overweight Vitamins _________________ Other ____________________

Please list medication(s) including vitamins, herbs & topical salves: _____________________________________________________ ____________________________________________________________________________________________________________ Do you take or use any products that contain the following (circle all that apply): Isotretinoin Tetracycline Retinoic Acid AHA Glycolic Acid Hydroquinone Aspirin Anticoagulent Have you recently had any type of chemical or glycolic peel? __________ If glycolic, what percentage? _________________________________________________________________________ If chemical, Please describe: _________________________________________________________________________ Any recent surgery or dermabrasion? _______ If yes, Please describe: __________________________________________________ Any allergies? ______________________________ Are you pregnant? _______Have you tanned in the last 24 hours? ___________ Is there anything else I should be aware of before your treatment? _____________________________________________________ Have you recently undergone surgery? (Medical or Cosmetic) __________________________________________________________ (please check () all that apply) Facial Analysis Skin Type __Normal __Dry __Combination __Oily __Sensitive/Breakout __Very sensitive/Rosacea __Acne __Mature What are your present skin concerns? ___Acne Lesion (cysts) __Acne Scars __Dilated Capillaries __Papules (inflamed) __Pustules (inflamed) __Black Heads __Whiteheads __Ingrown Hairs __Hyperpigmentation (Brown spots from sun, scars, hormonal) __Lack of Elasticity __Dark Shadows Eye Area __Crow's Feet/Wrinkles __Puffiness Mouth Area __Wrinkles __Hyperpigmentation __Nasolabial folds Check Area __Loss of elasticity __Cross wrinkling __ Sun Damage __Dilated pores __Uneven Texture __ Visible Capillaries Neck & Décolleté Area __Wrinkles __Severe Sun Damage __ Lack of Elasticity __ Hyperpigmentation __Regularly __Seldom __Never How often do you receive a facial?

Healthy Living Spa 611 East Hawkins Parkway, Longview, TX 75605, Spa (903) 3236510 * Fax (903) 3236520 www.GSMCInstitute.org

Confidential Consultation Form (pg3) Clients name: _______________________________________________

Last Informed Consent & Release Form Facials, Waxing, Dermabrasion, & Peels First M.I.

Please Read and Initial: _____ I have completed the Confidential Consultation Form accurately. I have been candid in revealing any conditions that could prohibit treatments(s), such as cold sores, pregnancy, use of hormones, recent facial surgery or laser resurfacing, recent use of RetinA TM or use of Accutane within the last 18 months. _____ I acknowledge that the possibility of an adverse reaction to a waxing, facial, dermabrasion and/or peel 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. _____ I fully understand that Healthy Living Spa and its agents may refuse to perform the treatments(s) I have requested if a contraindication is stated. I understand that I have given up substantial rights by signing this release and that it represents an agreement between me and Healthy Living Spa and me. I agree that my participation in treatment(s) is voluntary and I accept the inherent risks. _____ I hereby release Healthy Living Spa, 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 the information provided by me has been true and correct. I am over the age of 17 years old. I hereby authorize the therapist to perform said treatment(s). _____ The Esthetician has provided be the information necessary for me to have made the informed decision to proceed with the treatment(s). He/she has answered all of my questions concerning the treatment(s). I clearly understand the above information. __________________________________________________________________________________________ Client's Signature Today's Date __________________________________________________________________________________________ Esthetician's Signature Today's Date

Healthy Living Spa 611 East Hawkins Parkway, Longview, TX 75605, Spa (903) 3236510 * Fax (903) 3236520 www.GSMCInstitute.org

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