Client Form

All fields marked with an asterisk (*) are required.

Basic information

First Name *

Last Name *

Email *

Phone *

Address *

City *

Zipcode *

Birthdate *

Age *

Gender *

Additional Information

Marital status *

Profession or occupation *

Emergency contact

First Name *

Last Name *

Relationship *

Phone *

Primary Physician

First name *

Last name *

Clinic Name *

Phone *

Información Médica

Do you suffer or have you suffered from problems? *

Cardiac
Endocrine
Circulation
Digestive
Blood pressure
Others
No

Others:

Do you have any chronic diseases? *

Please specify:

Do you take medications, hormones, vitamins, supplements, topical treatments? *

Please specify:

Do you take steroid or prednisone medications? *

For how long?

Do you use or have you used Retin-A, Renova, Tazorac, Differin, Azelex or any other medical exfoliation products? *

For how long?

Have you had redness, allergies or herpes? *

Please specify:

Are you allergic to any medications, substance or food? *

Specify what type of allergies you suffer from:

Do you have a history of keloid scars? *

Have you been exposed to the sun without using sunscreen or have you been exposed to tanning beds in the last 6 weeks? *

Do you have tattoos or permanent makeup? *

Please specify where:

Have you had any surgery or cosmetic work recently? *

Please specify where:

Select your skin type *

Dry
Oily
Mix

Do you feel tightness or peeling on your skin? *

Do you smoke? *

Yes
No
Occasionally

Do you consume alcohol? *

Yes
No
Occasionally

Quality of sleep *

Good
Bad
Normal

Do you practice sports? *

What sport do you practice?

Are you a woman? *

Are you pregnant or could you be pregnant?

Were you recently pregnant?

Do you have a cesarean section?

Menstrual disorders?

Hormonal alterations? *

Please specify:

Have you performed one of the following procedures?

Laser straightening? *

Date:

Mild chemical peel? *

Date:

Medium/strong chemical peel? *

Date:

Microdermabrasion? *

Date:

Survey

How did you hear about us? *

Google
Facebook
TikTok
Recommendation
Radio
Television
Flyer
Other

Who?

Please specify:

HOJA DE EXONERACIÓN

I HAVE ANSWERED ALL OF THE ABOVE QUESTIONS TO THE BEST OF MY KNOWLEDGE, AND I UNDERSTAND THAT THE PROFESSIONAL MAY REFUSE TO PROVIDE THE SERVICES DUE TO CERTAIN HEALTH CONDITIONS. I ALSO UNDERSTAND THAT THERE MAY BE IRRITATION, REDNESS AND INFLAMMATION IN THE AREAS THAT HAVE BEEN WORKED. I also understand that if a doctor's note is required, I must provide the note to the esthetician prior to service.

I understand that I must inform the esthetician of any changes in my health, treatments or medications. I, the client, cannot hold SOLEIL responsible for any damage, loss, health, injury or reaction that occurs as a result of the treatment or service.

If the client is under 18 years of age, a parent or guardian must sign the authorization.

I accept Terms & Conditions *

Signature (Client, parent or guardian) *

Date time

¡Gracias por llenar el formulario!

Agradecemos que se comunique con nosotros. ¡Uno de nuestros colegas se pondrá en contacto con usted pronto!

¡Qué tengas un lindo día!

¡Gracias por llenar el formulario!

Agradecemos que se comunique con nosotros. ¡Uno de nuestros colegas se pondrá en contacto con usted pronto!

¡Qué tengas un lindo día!

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