Name: Lip Balm
Brand: Royal Esthetics
Price: 28.0 USD
Availability: InStock

Today's Date

Date

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email

example@example.com

Phone

Referred by

Emergency Contact

What do you do for a living/Where do you work?

Do you work:

In a high stress job? In an office with air conditioning? On an airplane? In a factory? In a restaurant around a lot of grease and oil?

What is the reason for your visit?

What special areas of concern do you have?

What conditions would you like to improve?

Have you ever had a facial treatment before?

Yes No

How would you describe your skin?

Normal Dry Oily Combination Sensitive Sun damaged I'm not sure how to describe it!

How would you rate your skin?

I Always burns, never tans Il Always burns easily, tans slightly III Burns moderately, tans gradually IV Seldom burns, always tans well V Rarely burns, deep tan VI Never burns, deeply pigmented

What is your racial background? VERY IMPORTANT IN TREATING YOUR SKIN

Do you ever experience

Flakiness? Redness? Tightness? Excessive oiliness during the day? None of these

What is your present skin regimen?

Soap & water only Cleanser Toner Mask Moisturizer Exfoliation Sunscreen every day None of these

Are you ever exposed to chemicals, oils or other caustic substances that may aggravate your skin?

Yes No

If so, what are they?

Do you blush easily?

Yes No

If so, what are the contributing factors?

Emotions Foods Temperature changes Other I'm not sure

Do you

Sun bathe? Use a tanning bed? I don't do any of these

Have you ever had

Chemical peels? Microdermabrasion Facial surgery Cosmetic surgery Botox Collagen injections Microneedling or Microchanneling Laser resurfacing None of these

If so, how recently?

Are you under treatment for any current skin condition?

Yes No

If yes, what skin condition?

Does your skin heal

Fast? Scars? Pigments? None of these

Do you bruise easily?

Yes No

Do you get sores/blisters (Herpes Zoster/Shingles)?

Yes No

What medications/hormone replacement/vitamins do you presently take?

Have you ever used

If so, when and how long?

Any personal or family history of skin cancer?

Yes No

How would you rate your overall health?

Excellent Good Fair Poor

Have you had any of the following (past or present)?

Do you smoke?

Yes No

Do you wear contact lenses?

Yes No

Have you had a reaction to

FOR WOMEN ONLY: Are you pregnant or trying to become pregnant?

Yes No

FOR WOMEN ONLY: Are you taking hormone replacement?

Yes No

FOR WOMEN ONLY: Do experience hormonal imbalances?

Yes No

FOR MEN ONLY: Do you shave with

Manual razor Electric shaver

MEN ONLY: Do you experience skin breakouts?

Yes No

MEN ONLY: Do you have ingrown hair and/or "razor bumps"?

Yes No

Is you stress level

High Medium Low

Do you normally sleep well?

Yes No

Do you have any food intolerances?

Yes No

Do you exercise regularly?

Yes No

Do you follow any special diet?

Yes No

How many glasses of water do you consume daily?

1-3 cups 4 or more cups I don't drink water

How many cups of caffeine-type beverages (coffee, tea, soft drinks) do you consume daily?

1-3 cups 4 or more I don't drink caffeinated beverages

In the treatment program, it may be necessary to recommend alterations or additions to your home care regimen. Would that be ok?

Yes No

If you are considering advanced skin care options, would you be interested in a payment plan (shop now, pay later)?

Yes No

Would you be interested in subscribing to our VIP email and/or text list (to stay informed of sales and specials)?

Email list only Text list only Both email and text list I would NOT like to be subscribed to the email or text list

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.

CLIENT INFORMED CONSENT: I do fully understand all the questions above and have answered them all correctly and honestly. I understand that services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.

I release and hold harmless Andrea M. Collins (owner) and Royal Esthetics, LLC (business) harmless from any liability for adverse reactions that may result from this treatment.

I have read and understood all the foregoing information

I agree to use electronic records and signatures.

POLICIES:

Cancellations (Same Day/Less than 24 hour advance notice)

We take the time to prepare for your scheduled appointment before your arrival. We are committed to providing you with exceptional service. When a client cancels without giving enough notice, they prevent another client from being seen. Please give 24 hours’ notice of any changes or cancellations. We understand that circumstances sometimes prevent you from keeping your appointments, but if 24-hour notification is not given, you will forfeit your deposit. Same day cancellations for Priority Booking clients will incur a fee equaling 50% of the service booked.

Same day cancellations for Priority Booking clients will incur fees equal to 50% of service fees.

Cancellations (24 hour or more advance notice)

Timely notification is encouraged and deposit will be applied to rescheduled time. ALL APPOINTMENTS MUST BE REBOOKED WITHIN 30 DAYS OF ORIGINALLY SCHEDULED APPOINTMENT. AFTER DAY 30 THE SERVICE WILL BE VOIDED AND MUST BE REPURCHASED (FORFEITING ORIGINAL DEPOSIT).

No Calls/No Shows

No calls/no shows will forfeit their deposit AND will not be able to schedule any appointments in the future. Deposits are non-refundable/non-transferable.

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Skin Health Treatment Consent

Lip Balm