Name
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First Name
Last Name
Phone
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(###)
###
####
Email
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Birthdate
MM
DD
YYYY
What is the best way to contact you?
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Select your preference(s)
Service(s) Requested
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Please leave days / times that work best for your schedule down below.
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Who referred you to Bliss Esthetics?
Are you allergic to anything?
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Yes
No
If yes, please list allergies:
Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?
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Yes
No
If yes, please list reason:
Have you had skin cancer?
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Yes
No
If yes, please list area(s):
Do you have any permanent cosmetics or tattoos on the areas being treated?
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Yes
No
Have you had any of these health conditions in the past or present?
Check all that apply
Do you smoke or chew tobacco products everyday?
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Yes
No
Do you follow a restricted diet?
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Yes
No
What is your current level of stress?
Low
Moderate
High
List any oral MEDICATIONS you take daily:
List all oral VITAMINS or HERBS you take daily:
Do you currently use any of the following?
Check all that apply
Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?
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Yes
No
If yes, please explain:
Do you use bleaching creams or Hydroquinone daily?
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Yes
No
Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
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No
Hyper-pigment
Hypo-pigment
Have you used an acne medication?
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Yes
No
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past?
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Yes
No
Have you ever had an ALLERGIC reaction to any of the following?
Check all that apply
Are you pregnant or trying to become pregnant?
Yes
No
Are you taking oral birth control?
Yes
No
Are you lactating?
Yes
No
Any current menopause problems?
Yes
No
If yes, please explain:
Do you wear foundation?
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Yes
No
When washing my face:
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I use hot water
I use warm water
I use cool or cold water
How often do you use a skin regimen?
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1x per day
2x per day
I do not use a regimen
Do you feel claustrophobic during facials?
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Yes
No
Do you have an aversion to hot or cold temperatures used on your face?
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Yes
No
What conditions would you like to improve?
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Check all that apply
List any additional conditions you would like treated:
Current skin care products you use at home. Include brand names and product names.
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. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Bliss Esthetics and/or the skin care professional from liability and assume full responsibility thereof.
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OPTIONAL: I grant permission to Bliss Esthetics to use photos of my progress for marketing purposes on www.blissestheticsjaz.org/ or other business listing pages such as Instagram.
Today's Date
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MM
DD
YYYY
