Tender Touch Therapeutic Skincare

Client Intake

Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Phone *
Phone
Emergency Contact Phone Number *
Emergency Contact Phone Number
MEDICAL
Do you have any health problems we need to be aware of or under a Dr.'s care? *
Do you have any allergies? *
Have you had any recent surgery, cosmetic or medical? *
Have implants? *
Are you taking any medications (prescription/OTC)? *
Do you smoke? *
Please check any below that you are currently taking or that you've taken in the past 12 months: *
Please check if you have/had any of the following: *
SUN & GENETICS
Can you tan? *
Have you ever sunburned? *
Ever used a tanning bed? *
Skin Conditions - Please check any that pertain to you: *
NUTRITION
Fat free/low fat diet? *
SKINCARE
Have you ever had a professional skincare treatment? *
Have you had a "peel" of any kind (enzyme, AHA, BHA, TCA, Jessner, medical-grade) in the past 12 months? *
Which skincare products and brands are you currently using?
What do you consider your skin type? *
Are you open to using Osmosis recommended product line? *
I have read the Tender Touch Skincare Policies and understand that if I do not show up for my appointment and fail to call to cancel 24 hours in advance, a fee of $75.00 will incur on my credit card. *
I certify that all of the above information is true to the best of my knowledge. I understand that the services received here are not a substitute for medical care and any information given by the Esthetician is for education purposes only. *
Signature *
Signature