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Gw organic facial intake 08215 Forest Park Circle Panama City, FL 32405 *Office 850-215-5657 CONFIDENTIAL SKIN HEALTH SURVEY
Name: ____________________________ Date of Birth: ____/____/____ Intake Date: ____/____/_____ Address: _____________________________________ Your Occupation ______________________________ Emergency Contact-Name: ___________________________ Address: ____________________________________ Who referred you to this office? _______________________ Please list your current Dermatologist/Physician: ________________________________________________ Please provide a brief explanation of your reason for today’s visit and any concerns you may have: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ IF APPLICABLE, CIRCLE ANY SKIN CONDITIONS/ISSUES YOU WISH TO ADDRESS:
Gentle treatment of the body and others) SKIN HEALTH SURVEY (Continued)
If yes, how long ago was your last skin treatment? _____________ Have you had a Chemical Peel or Microdermabrasion? Please describe __________________________________________________ Do you have Acne? Yes No Hyper-pigmentation? Yes No Do you have any other skin conditions? ____________________ If yes, please explain: ________________________________________________________________ Do you experience frequent blemishes? __________________ Do you have any allergies to food, herbs, plants, trees, seafood, cosmetics or drugs? Please list_______________________________________________________ Are you presently taking medications (oral or topical)? Please list_______________________________________________________ Water ____, Coffee/Tea ____, Soft Drinks ____, Alcoholic Drinks ____ How would you rank your level of general stress experienced (1 Low to 10 High)? __________ Please describe __________________________________________________________ Are you currently involved in a fitness program? Yes Please describe __________________________________________________________ Please describe _____________________________________________________________ SKIN HEALTH SURVEY (Continued)
Please circle any that you are currently using or have used: (Azelex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alphahydroxy acid) Please describe usage history ________________________________________________________ Are you presently under a Physician’s care for any current skin condition or problem? Please describe ____________________________________________________________________ Please mark if you are affected by or have any of the following: Urinary or Kidney problems _______________ Varicose Veins/Swollen legs _______________ Bad digestion or constipation _______________ Please explain above problems or list any health concern: _____________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ I understand that the information herein is to aid the Skincare specialist in giving better service and is completely confidential. Skin Care Policies: 1. We require a 24-Hour cancellation notice or a cancellation fee of $50 is due. 2. Joining a Green Wave wellness plan does qualify you for a 10% discount off of services. I fully understand to the above Green Wave/Frida policies. _______________________________ 215 Forest Park Circle Panama City, FL 32405 *Office 850-215-5657 Skin Health Treatment Consent and Release
I acknowledge that the practice of massage and nail, hair, and skin care treatments including microblation, microdermabrasion, electrolysis, facials, body treatments, facials, toning, TPR treatments, laser treatments, and various other beauty treatments are not an exact science and no specific guaranties can or have been made concerning the expected result. I understand that some clients experience more change and improvements to become apparent than others. I also realize that the following risks and hazards may occur in connection with any particular treatment including but to limited to: unsatisfactory results, poor healing, discomfort, redness, blistering, nerve damage, scarring, change in the skin pigmentation, and increased hair growth. I understand that even though precautions may be taken in my treatment, not all risks can be known in advance. Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. I also agree to hold harmless and release liability for Green Wave Family Wellness Center and Frida natural Dermabalance as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown that may arise as a result of any treatment that I receive. ____________________________ ____________________________ ____________________________
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