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Welcome
Mission
Menu
Home
Etiquette
Aftercare
Sohl Club
Forms
Contact
Forms
FORMS
INFORMATION |
CONSENT
|
feedback
|
SKIN ANALYSIS
|
TREATMENT PLAN
CLIENT INFORMATION
CLIENT INFORMATION FORM
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Questions
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
No
Yes
Are you using Retina, Renova or Accutane (an oral form of Retina)?
No
Yes
Are you using any other skin thinning products and/or drugs?
No
Yes
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
*
No
Yes
Are you diabetic?
No
Yes
Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):
What skin products do you regularly use on your skin?
Have you ever been treated for cancer? If yes, when and what types of therapies were used?
Please list any other illness/condition you are currently being treated for by a medical professional:
Female Clients: When is your next menstrual cycle due to begin?
Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days afer it is completed.
MM
DD
YYYY
Have you ever had a facial treatment before?
No
Yes
When?
MM
DD
YYYY
Have you ever had a body spa treatment before?
If yes, please check all that apply
No
Massage
Salt Glow
Seaweed Wrap
Moor Mud
Body Scrub
Other
When?
MM
DD
YYYY
Which of the following best describes your skin type?
Please check one
Creamy complexion: Always burns easily, never tans
Light Complexion: Always burns, tans slightly
Light/Matte Complexion: Burns moderately, tans gradually
Matte Complexion: Seldom burns, always tans well
Brown Complexion: Rarely burns, deep tan
Black Complexion: Never burns, deeply pigmented
What skin care products are you currently using?
List brand where known
Have you recently used any self-tanning lotions, creams or treatments?
No
Yes
If yes, please specify:
Have you used any of the following hair removal methods in the past six weeks?
Please check all that apply
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
What areas of concern do you have regarding your skin?
Please check all that apply, and explain
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other
Explanation:
and/or "Other Concern" if not listed above
What areas of concern do you have regarding your eyes?
Please check all that apply
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
Have you ever had an allergic reaction to any of the following?
Please check all that apply, and explain
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine | Pollen | AHAs
Fragrance
Shellfish
Latex
Drugs
Other
If yes, please explain:
What SPF do you use on your face?
How often and when?
What SPF do you use on your body?
How often and when?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
If yes, please specify:
Have you experienced Botox, Restylane or Collagen injections?
If yes, please specify:
Female Clients Only
Are you taking oral contraceptives?
No
Yes
Any recent changes to or from your contraceptive treatment?
No
Yes
If yes, please specify:
Are you pregnant or trying to become pregnant?
No
Yes
Are you lactating?
No
Yes
Any menopause problems?
No
Yes
Are you undergoing any hormone replacement therapy?
No
Yes
Male Clients Only
What is your current shaving system?
Wet Shave
Electric
Do you experience irritation from shaving?
No
Yes
If yes, ingrown hairs?
No
Yes
Future Appointments / Contact:
May I call you at your home, work or cell phone number to confirm future appointments?
No
Yes
May I contact you via mail/email about future promotions and news?
No
Yes
May we take photos of you to use on our social media platforms?
No
Yes
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Thank you!
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CLIENT CONSENT
CLIENT CONSENT FORM
I hereby consent to and authorize SOHL to perform the following procedure and any & all procedures from today forward:
Chemical peels, microdermabrasion, facials, waxing, eyelash extensions, lash lifs, brow & lash tinting, message therapy and finger nails.
I have voluntarily elected to undergo this treatment/procedure afer the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by SOHL.
I have read the entire website that provides all information to me and I have initialed the above sections to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my skin therapist. I give permission to my therapist, SOHL, to perform any and all procedures of my choice that we have discussed and will hold him/her and his/her staff harmless from any liability that may result from this treatment. I understand he/she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I have given an accurate account of any over-the-counter or prescription medications that I use regularly and I am not presently using isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my therapist. I am not ingesting or using topically any other over- the-counter product or prescription medication/agent that has not been disclosed to my therapist. I am not presently pregnant or lactating and I am over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn, or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, excessive telangiectasia, rosacea, bacterial skin infections, fungal infections, viral infections, open lesions or rashes, active acne, any auto immune disease, eye infections, existing & current STD’s or any other existing condition that may interfere with the positive outcome of this treatment.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I understand the potential risks and complications and have chosen to proceed with the treatment afer careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I agree that I am willing to follow recommendations by my esthetician & therapist for home care. I understand how important it is to follow all instructions given to me for post-treatment care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions.I agree to use a moisturizer specifically recommended by my esthetician and I acknowledge that I have been informed of the possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my therapist immediately.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I have also, 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.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I understand that I should not have a chemical peel, microdermabrasion completed if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my therapist.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne condition.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or afer I return home.
*
By checking this box and typing my initials below, I am electronically signing this document.
Check if you agree
Type Initials:
*
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
*
By checking this box and signing my name below, I am electronically signing this document.
Check if you agree
Client Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Thank you!
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CLIENT FEEDBACK
CLIENT FEEDBACK FORM
Services Performed Today
Would you recommend me to your friends?
No
Yes
Would you come back in future?
No
Yes
The treatment room was clean, private, and relaxing
No
Yes
The overall atmosphere was professional and relaxing
No
Yes
The esthetician was friendly, knowledgeable, and professional Your appointment started and finished on time
No
Yes
Your payment was processed in a timely manner
No
Yes
Your treatment was good value for the cost
No
Yes
Were your expectations for today’s visit met?
No
Yes
Do you feel your needs and concerns were addressed?
No
Yes
How did you first hear about my services?
On a scale of 1 to 5, with 5 being the best, how was your overall experience today?
*
5 - Perfect
4 - Excellent
3 - Good
2 - Average
1 - Poor
What did you like best about the treatment you had today?
Was there anything I could have done better/do differently for you next visit?
Do you have any questions that were not addressed?
If yes, please note
Any other comments:
Thank you!
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