The Powder Room New Client Information Form

Our Client Information Form helps us gather important information about you including your skin care regimen, skin concerns, and medical information relevant to skin treatments. The form helps us customize services based on your skin care needs and goals. It also helps us identify any potential contraindications or allergies. Completion of this form is required before any facial service can be provided. We appreciate your understanding, as it allows us to deliver the safest and most effective experience.

Cell Phone (this number will be used to follow-up with you via text message after your service)

Emergency Contact Full Name and Number

Are you over the age of 18?

Name of parent/legal guardian completing the form (if under the age of 18):

Do you have any health/medical conditions? Please note that some conditions and illnesses may affect certain treatments.

If yes, please describe:

Please consult your physician and obtain medical clearance from your doctor prior to service/treatment if you have any medical and/or skin conditions.

Do you currently take prescribed or over-the-counter medication?

List any medications you currently take, including over-the-counter (e.g. aspirin, antihistamine, acne products, Ibuprofen (Advil, Motrin), naproxen (Aleve), etc.):

Are you currently seeing or have you seen a dermatologist within the past year?

If yes, please explain, including skin conditions:

Do you currently use or have you used any of the following in the last three months? Select all that apply

It is generally recommended that you wait at least 6 months after finishing Accutane and 2-3 weeks after Retin-A before undergoing certain skincare treatments.

Indicate any skin conditions (select all that apply).

Do you have any allergies (topical or internal)?

If yes, list any known allergies:

Do you have any of the following? Select all that apply.

Skin Type / Skincare History

What does your skin do when exposed to the sun?

Which of the following best describes your skin type?

What concerns do you have regarding your skin? Select all that apply.

If Other, please describe:

Indicate all skin care products you currently use:

If Other, please list :

Have you ever had a reaction to skin care products or cosmetic products?

If yes, indicate the product(s) and describe your reaction:

Have you recently received Botox, Dermal Fillers, Restylane, Collagen, or other facial injections in the last month?

It is recommended to wait 1 - 2 weeks after injection before getting a facial.

Do you exfoliate weekly?

Is this your first facial?

Have you had any professional skin treatments in the past 6 months (dermaplaning, chemical peel, laser treatment, microdermabrasion, microneedling, injectables, other professional treatments?

If yes, indicate the treatment(s):

Have you ever experienced any irritation, allergic reactions, or sensitivities from a professional skin care service?

If yes, indicate service(s) and reaction:

What are your skin care goals?

Are you pregnant or lactating?

Are you undergoing any hormone replacement therapy?

Have you used any of the following facial hair removal methods in the past two weeks?

Please refrain from face sugaring, waxing, tweezing, threading, or using depilatories the week leading up to and after your facial service.

What are your facial hair habits?

If you shave your face, what grooming tools do you use?

Do you experience irritation from shaving

If yes, please describe:

Do you experience or have ingrown hairs?

Acknowledgement & Release

By signing this form, I agree to the following:

I understand, have read and completed this Client Information From truthfully. I agree that this constitutes full disclosure. I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to he skin from treatments received.

I acknowledge that certain ingredients, medical conditions, prescriptions, and skin conditions may contraindicate the treatments, modalities, and potentially impact the results of the treatment, leading to serious injury and potential scarring. The services/treatments I receive at The Powder Room are voluntary and I release The Powder Room and the Licensed Esthetician from any liability that may result from the services/treatments I receive, and I assume full responsibility thereof.

I acknowledge that my facial service/treatment will include professional strength products and may also include extractions, high frequency, LED light therapy, and other treatment modalities as necessary.

I understand that this is a cosmetic service/treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one service/treatment, and I need to follow the maintenance home protocol.

I understand that with some treatments, there may be some degree of discomfort (i.e. stinging, "pin-pricking" sensation, hotness, or tightness.

I have read and understand the Enzyme and Chemical Peel Prep Guidance and Enzyme and Chemical Peel Aftercare Guidance posted to The Powder Room website.

By signing below, I confirm that I have read, understand, and agree to the statements and consent to proceed with the requested service(s).

I am over the age of 18 and have read, understand, and agree to the statements, and I consent to proceed with the requested service(s).

As the parent/legal guardian of the minor client, I have read, understand, and agree to the statements, and I consent to the minor client receiving the requested service(s).

First and Last Name of Person Signing

Signature

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The Powder Room New Client Information Form

Cell Phone (this number will be used to follow-up with you via text message after your service)

Emergency Contact Full Name and Number

Are you over the age of 18?

Name of parent/legal guardian completing the form (if under the age of 18):

Do you have any health/medical conditions? Please note that some conditions and illnesses may affect certain treatments.

If yes, please describe:

Please consult your physician and obtain medical clearance from your doctor prior to service/treatment if you have any medical and/or skin conditions.

Do you currently take prescribed or over-the-counter medication?

List any medications you currently take, including over-the-counter (e.g. aspirin, antihistamine, acne products, Ibuprofen (Advil, Motrin), naproxen (Aleve), etc.):

Are you currently seeing or have you seen a dermatologist within the past year?

If yes, please explain, including skin conditions:

Do you currently use or have you used any of the following in the last three months? Select all that apply

It is generally recommended that you wait at least 6 months after finishing Accutane and 2-3 weeks after Retin-A before undergoing certain skincare treatments.

Indicate any skin conditions (select all that apply).

Do you have any allergies (topical or internal)?

If yes, list any known allergies:

Do you have any of the following? Select all that apply.

Skin Type / Skincare History

What does your skin do when exposed to the sun?

Which of the following best describes your skin type?

What concerns do you have regarding your skin? Select all that apply.

If Other, please describe:

Indicate all skin care products you currently use:

If Other, please list :

Have you ever had a reaction to skin care products or cosmetic products?

If yes, indicate the product(s) and describe your reaction:

Have you recently received Botox, Dermal Fillers, Restylane, Collagen, or other facial injections in the last month?

It is recommended to wait 1 - 2 weeks after injection before getting a facial.

Do you exfoliate weekly?

Is this your first facial?

Have you had any professional skin treatments in the past 6 months (dermaplaning, chemical peel, laser treatment, microdermabrasion, microneedling, injectables, other professional treatments?

If yes, indicate the treatment(s):

Have you ever experienced any irritation, allergic reactions, or sensitivities from a professional skin care service?

If yes, indicate service(s) and reaction:

What are your skin care goals?

Are you pregnant or lactating?

Are you undergoing any hormone replacement therapy?

Have you used any of the following facial hair removal methods in the past two weeks?

Please refrain from face sugaring, waxing, tweezing, threading, or using depilatories the week leading up to and after your facial service.

What are your facial hair habits?

If you shave your face, what grooming tools do you use?

Do you experience irritation from shaving

If yes, please describe:

Do you experience or have ingrown hairs?

Acknowledgement & Release

By signing this form, I agree to the following:

I understand that with some treatments, there may be some degree of discomfort (i.e. stinging, "pin-pricking" sensation, hotness, or tightness.

I have read and understand the Enzyme and Chemical Peel Prep Guidance and Enzyme and Chemical Peel Aftercare Guidance posted to The Powder Room website.

By signing below, I confirm that I have read, understand, and agree to the statements and consent to proceed with the requested service(s).

I am over the age of 18 and have read, understand, and agree to the statements, and I consent to proceed with the requested service(s).

As the parent/legal guardian of the minor client, I have read, understand, and agree to the statements, and I consent to the minor client receiving the requested service(s).

First and Last Name of Person Signing

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

The Powder Room New Client Information Form

Medical Information

Skin Type / Skincare History

For Women

For Men

Acknowledgement & Release

The Powder Room New Client Information Form

Medical Information

Skin Type / Skincare History

For Women

For Men

Acknowledgement & Release