Book a Skincare Appointment | Aura & Ink Walnut Creek

DATE

NAME

DATE OF BIRTH

EMAIL ADDRESS

ADDRESS

PHONE NUMBER

OCCUPATION

HOW WERE YOU REFERRED TO US?

History

Are you currently under the care of a physician for any reason?

List of Medication, supplements, and vitamins?

Allergies?

Current Skin and Lifestyle

How do you wash your face?

Do you moisturize?

Are you on a special diet?

Do you consume water daily?

How much water?

Do you exercise?

Have you had a facial?

Do you give yourself facials at home?

List products you are using?

Additional notes

I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical and health conditions and to update this information at subsequent visits.
A current history is essential for the provider to execute appropriate treatment procedures. I have signed the consent for this procedure. I had the opportunity to ask questions prior to the treatment. I accept arbitration as a means of resolution for practice liability

Client Signature

Date

Booking

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