Health Questionnaire Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Date of Birth * MM DD YYYY Email * Referred By: First Name Last Name What products are you currently using on your skin? * What is the reason for your visit? * Have you had any facial injections if so what and when? * What water temperature do you prefer when bathing? * Hot Warm Lukewarm When receiving a massage do you prefer: * Firm pressure Medium Pressure Light pressure When you go out into the sun do you: * Always Burn Usually Burn Tan without difficulty Mild burn, tan easily Rarely burn Very rarely burn Tans easily Doesn't burn, tans very easily Have you or anyone you have come in contact with in the past 10 days been exposed or had Covid19? * Yes No Do you have allergies to any of the following? * Aspirin or aspirin products Benzoyl peroxide Glycolic acid Latex gloves Sulfur Products Rubbing Alcohol Witch Hazel Aloe Vera Vitamin E, D, C, A Are you currently under the care of a physician for a specific condition? If yes, list reason(s) List any and all medications you are taking (include ointments and creams prescribed by a physician) * Mark any of the following that apply to you: Epilepsy Smoker Heart Problems Blood Thinners Contact Lenses Keloid Scars and skin conditions Eczema Diabetes Vascular Lesions Active Acne Skin Cancer Pregnant/Nursing Sinus Infections Hepatitis Facial/Oral Surgery Facial Implants Dermatitis Auto immune disease High/low blood pressure Viral Lesions/Herpes Using any Retin-A, Salicylic acid, Alpha or Beta Hydroxy Products or Accutane When was your last facial treatment and what type of treatment was performed? Digital Signature My signature states that I agree to assume the risk of any injury or damage that I or the minor I am signing for might incur. This including but not limited to redness, crusty skin, breakouts, oozing, infection, allergy to any chemicals or wax products such as peels, broken capillaries and or scarring. I agree to rescind my right to sue Lisa Albera and or anyone performing these services. I have careful read and understand this is a release of liability and sign this of my own will. First Name Last Name Thank you!
