Are you currently on/have you ever taken any of the following medications?
Please list any other current & past medications and what they are treating:
Check all the following medical procedures and conditions that apply to you:
(Check all that apply)
Please list your allergies:
Please list any other current illness you may have:
Are you pregnant and/or breastfeeding?
Have you ever been diagnosed and/or treated for cancer?
Please provide some details about your diagnosis / treatment:
Are you currently taking any herbal or nutritional supplements?
Please list herbal or nutritional supplements you are currently taking:
Do you suffer from a hormonal imbalance?
Are you currently on hormonal replacement therapy (HRT)?
Do you wear contact lenses?
Have you ever had any of the following treatments?
Check all that apply
If yes to any of the above, please indicate the date of last treatment
If yes to any of the above, were your expectations met?
Lifestyle & Diet
How would you rate your stress level?
How would you rate your current diet?
Do you normally sleep well?
Do you exercise regularly
Do you have food intolerances?
How many glasses of water do you consume daily?
How many cups of caffeinated beverages do you consume daily?
Please Review & Agree
I have read and will follow to the best of my abilities any and all instructions. I will let my practitioner know if I start any new medications, skin care products, become pregnant or have undergone any treatments at other facilities that could possibly affect the outcome of my treatment program at SKN Holistic Rejuvenation Clinic:
Once we have confirmed your appointment, we require a minimum of 24hrs notice before your appointment time for cancellations or changes for appointments up to 60 minutes in length. For appointments longer than 60 minutes, we require 48hrs.
Failure to provide adequate notice, or no-showing, will result in a $50 late cancellation fee and
no-shows will also be required to pay in full in advance to re-book.
All new clients must provide a credit card number to book their first appointment. Also, clients booking multiple appointments (for themselves and a friend) will be required to provide a credit card to hold their spots.
Do you agree with the above statement?