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CLIENT CONSULTATION & HEALTH FORM

Whether you receive treatment for wrinkles, acne, hair removal, or something else, your health, allergies, medical history, and a list of the current products you use are necessary to determine what products, equipment, and treatments are appropriate for you.

 

Please fill out the form below for your safety. Your responses are confidential and only for the purpose of providing the best possible care. If question does not apply to you, feel free to write "N/A."

Birthday
How did you hear about Thais Leal Skin Studio?
Google Search
Instagram
Online Reviews
Personal Referral
Professional Referral
Trade Show or Conference
Word of Mouth
Other
What are your skin concerns?
Have you received any Botox or fillers in the past four (4) weeks?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Please select all health conditions that apply to you:
Are you currently taking Aspirin or any blood thinners?
Yes
No
Please indicate which of the following products you are currently using:
Please indicate if you have any allergies to the following:
Have you had any surgeries that required placement of a Pacemaker or metal rods/screws?
Yes
No
Are you currently seeing a dermatologist?
Yes
No
Do you smoke?
Yes
No

Consent

To the best of my knowledge, I have given an accurate account of my medical history. This includes all my known allergies and the prescription drugs and products I am currently using. Althought it is impossible to list every risk, I am aware of the possible benefits, risks, and complications. I also recognize there are no guaranteed results, as results depend on age, skin condition, and lifestyle. I may need more treatments to achieve desired results, which carry extra costs. I understand how important it is to follow all instructions given to me for post-treatment. In the event that I may have additional questions or concerns about my treatment or suggested post-treatment care, I will consult the esthetician immediately. I do not hold Thais Leal Skin Studio or any of its employees responsible for any conditions that I did not disclose at the time of the procedure, which may be affected by the treatment performed today.

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