Name *
Name
Address
Address
Skin Type
Current Skin Conditions
Conditions you are currently experiencing
Please select all that apply
Which aroma(s) do you prefer?
Please select all that apply
Are you under the care of a Dermatologist
This may include cosmetics, AHAs, Fragrance, Latex, Sunscreen, etc
If yes, please specify
If yes, please specify:
Signature *
Signature
By Signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and Age Later Aesthetics for any injury or damages incurred due to any misrepresentation of my health history.
Date
Date