New Guest Skin Health QuestionnairePlease take a few moments to complete this form about your skin, your concerns, and what you are seeking from our time together. Thank you. Name * First Name Last Name Preferred Pronouns Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Preferred Phone * (###) ### #### Preferred Method of Contact Call Text Email Occupation/Job/Student * Does your job require you to work outdoors? Yes No How did you learn about Mansfield Hollow Skincare? What would you like to achieve from your treatment today? * Have you ever had a facial treatment before? * Yes No If yes, when? Which best describes your skin type? * 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 Do you have any special skin problems or concerns pertaining to your face or body? * Yes No If yes, please specify Have you ever had chemical peels, laser or microdermabrasion? * Yes No In the last month? Yes No N/A Do you use Prescription topical products like Retin-A, Renova, Adapalene, Hydroxyl Acid products? * Yes No Have you had Botox, Restylane, Fillers or Collagen injections in the last 2 weeks? * Yes No What skincare products are you currently using? Would you like to go over your current skincare regimen? * Yes, I want learn which products are best for my skin concerns. No, I am pleased with the results of my current regimen. No, I am only here to relax. Have you used any of these facial hair removal methods in the past six weeks? Shaving Tweezing Waxing Threading Electrolysis Depilatories Dermaplaning What areas of concern do you have regarding your Skin? * Breakouts/acne Rosacea Uneven skin tone Dull/dry skin Blackheads/whiteheads Broken capillaries Sun damage Flaky skin Excessive oil/shine Redness/ruddiness Wrinkles/fine lines Dehydrated Eye puffiness/dark circles Sun spot/liver spot/brown spot NONE, I have no areas of concern What have you done about this concern so far? Have you ever had an allergic reaction to any of the following? * Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs Skincare products No, I have never had an allergic reaction Please explain Do you have intolerance to Hot or Cold? Hot Cold Are you Claustrophobic? * Yes No Please list any health conditions such as heart conditions, cancer, thyroid disease Do you have a family history of skin cancer? * Yes No Have you ever had any of the following skin conditions? Check all that apply Skin Infection Herpes (cold sores) Sun Sensitivity Poor Healing Easy Bruising Eczema Psoriasis Lymph Nodes Removed Diabetes Keloids/Excessive Scarring Current medications and/or vitamins * Dietary Considerations Have you had any recent tanning bed or sun exposure that changed the color of your skin? * Yes No If yes, please specify Are you taking oral contraceptives? Yes No If yes, please specify Any recent changes to or from your contraceptive treatment? Yes No If yes, what and when? Are you pregnant or trying to become pregnant? * Yes No Are you lactating? * Yes No Any menopause problems? Yes No If yes, please specify Are you undergoing any hormone replacement therapy? Yes No If yes, please specify Ingrown Hairs? Yes No Check to show you agree: * I understand that every procedure/treatment is followed by a period of healing before the tissue returns to normal and the final result is apparent. Check to show you agree: * I understand that my goal is overall improvement and not perfection. Check to show you agree: * I understand that I may need several treatments to see improvement. Check to show you agree: * I understand that some facial treatments may leave my skin red, inflamed, scabby or peeling for 1-2 weeks, and I will not hold Mansfield Hollow Skincare LLC liable. Check to show you agree: * I have fully disclosed any and all concerns, medical issues, and prescription medication use prior to my treatments. Check to show you agree: * Since reservations are planned to allow the correct time for each treatment, it's important to be punctual. Enough extra time is reserved so you can change clothes, complete any necessary paperwork, and begin your experience without worries. I require 24-hours notice if you need to cancel or reschedule your treatment. Remember, it is your responsibility to remember your appointments ... as a courtesy, confirmation is made 24-hours in advance via email and text. Due to an unfortunate increase in "no-shows" and last minute cancellations, a credit card may be required to hold your first reservation. If last minute rescheduling or cancellation of your reservation occurs, or if you fail to show up for your scheduled reservation, Mansfield Hollow Skincare, LLC reserves the right to charge the full price of the service(s) reserved to your credit card. Cancellation fees are as follows: 24-Hours or more advance notice = no fee. Less than 24-hours notice = 50% of reserved service(s), or $30, whichever is greater. No notice given (no show) = 100% of the reserved service(s), or $30, whichever is greater. By confirming your reservation over text or phone, you agree to the terms of this policy. Please acknowledge MHS Policies by typing name * First Name Last Name Thank you for taking the time to complete this information! Bring your best skin to life,Sara
