Client Consultation - ASCP
Date: _______________________________Name: ________________________________________ __________________ Date of Birth: _________________Address: ________________________________________ ________________________________________ ________Home Phone: __________________________________Busine ss Phone: __________________________________ Cell Phone: _____________________________________E-m ail address: __________________________________ Single: m No m Yes Married: m No m Yes If yes, anniversary date: ___________________Employer: ________________________________________ _Occupation: __________________________________ Does your job require that you work outdoors? m No m YesReferred by: ________________________________________ ________________________________________ _____What would you like to achieve from your treatment today? ________________________________________ ____Your Skin Care1) Have you ever had a facial treatment before?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ-ous 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.
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