Name
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First Name
Last Name
Email
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Phone
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How did you hear about Inner Beauty Esthetics?
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Have you experienced any of the following symptoms in the past 48 hours: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting/diarrhea?
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Are you under a Doctor's care for any reason? Please check all that apply.
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Are you pregnant, expecting to become pregnant or breastfeeding?
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Are you currently taking birth control?
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Do you have any metal implants or medical devices in your body?
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Do you have any known allergies? If yes, please list your allergies below.
Are you allergic to Aspirin?
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Are you prone to keloid scarring?
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In the last 12 months, have you had any of the following laser treatments?
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What ethnicity do you identify with?
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How would you describe your skin? Please check all that apply.
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What are your main skincare concerns? Please check all that apply.
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Are you using any of the following prescription products? Please select all that apply.
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What type of products are you currently using in your home routine?
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Do you use any of the following at-home tools or devices? Please select all that apply.
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Are you outdoor often?
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Do you wear sunscreen daily?
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How is your daily diet? Please check all that apply.
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How many hours of sleep do you get a night?
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How is your daily water intake?
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How many cups of caffeine-type beverage (coffee, tea soda) do you consume daily?
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Do you use cannabis or tobacco products?
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How often do you exercise?
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How often do you consume alcohol?
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How committed are you to achieving results and your skincare goals?
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I understand the skin care treatments I receive at Inner Beauty Esthetics may causes the skin to ‘’purge’’ post- treatment. Skin purging is a temporary skin reaction during which the skin becomes dry, red, and irritated and experiences minor breakouts in response to the skin regeneration, repairing process and or when a new product a person has introduced into their skin care regimen.
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I understand the skin care treatments I receive at Inner Beauty Esthetics are voluntary and I release Inner Beauty Esthetics from liability such as physical injury, allergic reactions, and assume full responsibility thereof.
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I give permission to Inner Beauty Esthetics to use any still photographs or videos taken during my treatment for use on their website or other promotional materials. I understand that Inner Beauty Esthetics will own all rights to these items.
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
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