Client Medical History

	Hair Removal Method	Where on Body
1

	Hair Removal Method	Where on Body
2

	Hair Removal Method	Where on Body
3

	Hair Removal Method	Where on Body
4

	Allergen	Details/Reaction	Please list if Food/Meds/Other:
1

	Allergen	Details/Reaction	Please list if Food/Meds/Other:
2

	Allergen	Details/Reaction	Please list if Food/Meds/Other:
3

	Allergen	Details/Reaction	Please list if Food/Meds/Other:
4

	Allergen	Details/Reaction	Please list if Food/Meds/Other:
5

	Description	Area(s)
1

	Description	Area(s)
2

	Description	Area(s)
3

	Description	Area(s)
4

	Description	Area(s)
5

	Description	Area(s)
6

	Brand (e.g. Elta MD)	Product Name (e.g. Foaming Facewash )	Frequency (e.g. 2x Daily)
1

	Brand (e.g. Elta MD)	Product Name (e.g. Foaming Facewash )	Frequency (e.g. 2x Daily)
2

	Brand (e.g. Elta MD)	Product Name (e.g. Foaming Facewash )	Frequency (e.g. 2x Daily)
3

	Brand (e.g. Elta MD)	Product Name (e.g. Foaming Facewash )	Frequency (e.g. 2x Daily)
4

	Brand (e.g. Elta MD)	Product Name (e.g. Foaming Facewash )	Frequency (e.g. 2x Daily)
5

	Device/Implant	Area	If other, please list
1

	Device/Implant	Area	If other, please list
2

	Device/Implant	Area	If other, please list
3

	Device/Implant	Area	If other, please list
4

	Treatment	Area	Please list if other:
1

	Treatment	Area	Please list if other:
2

	Treatment	Where on Body	Please list if other:
1

	Treatment	Where on Body	Please list if other:
2

	Treatment	Where on Body	Please list if other:
3

	Treatment	Where on Body	Please list if other:
4

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
1

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
2

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
3

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
4

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
5

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
6

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
7

	Name of Medication	Prescribed/Taken for	Dosage (g, mg, iu)	Frequency
8

	Name of Medication	Prescribed/Taken for
1

	Name of Medication	Prescribed/Taken for
2

Simply Skin Las Vegas

Policies
Name (must match your state issued ID): *

First NameLast Name
CANCELLATION POLICY: Your appointments are very important to us, and are reserved especially for you. Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding as it is never our intention to cause our clients any inconvenience. Please understand that when you forget or cancel your appointment without giving enough notice, we miss the opportunity to fill that time for clients on our waiting list. Our appointments are confirmed 48 hours in advance because we know how busy our clients are. Cancellations less than 48 hours will be subject to a fee. No call/no shows and same day cancellations will result in a charge of 100% of services booked. Cancellations less than 48 hours will result in a charge of 50% of services booked.*

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INITIALS
COMMUNICATION: We send you direct (not automated) non-promotional text messages regarding your appointments. If at any time you wish these messages to stop, please notify the front desk by either texting back STOP or calling.*

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INITIALS
CHILDREN’S POLICY: For their safety, children may not enter the treatment areas at any time. For their protection, children are only permitted in the waiting area while accompanied by another adult. We appreciate your understanding!*

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INITIALS
PETS: For the comfort and safety of all guests, we ask that you do not bring pets into the salon. We understand that service animals are not pets, and are the only exception to the rule.*

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INITIALS
REFUNDS/RETURNS/EXCHANGES: Due to the nature of our business we do not offer refunds, returns, or exchanges of any service, package, or product *

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INITIALS
LASER TECHNICIAN REQUESTS: Due to the nature of scheduling with our establishment and the way we run our practice; we do not take laser technician requests. *

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INITIALS
QUESTIONS/COMPLAINTS

We have taken great measures to ensure that your experience is an excellent one. We foster an environment where clients can come freely to discuss any questions or concerns by using the information below:

Contact Person: Office Manager
Telephone: (702) 823-0852
Email: info@simplyskinlasvegas.com
Date*

MonthDayYear
Date
ACKNOWLEDGMENT: I have carefully read and agree to pay Simply Skin Las Vegas’s Cancellation Policy Fees, and hereby authorize Simply Skin Las Vegas to bill or charge my credit card for that amount.*

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CLIENT SIGNATURE
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If minor, guardian signature
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Client Information & Medical History

MEDICAL HISTORY

Do you have or have you had any of the following medical conditions listed below?

IF APPLICABLE:

MEDICATIONS

Simply Skin Las Vegas