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Client

Profile Form

Please fill out our client profile form below. If you have any issues with this form, or you have a question, please email us at ContactUs@Flawless-Reflections.com or give us a call at 480-659-9828.

1Client Information

2Medical History

3General Health Questions

4Skin History

Name*
Gender*
- Male
- Female
Birthdate*
MM slash DD slash YYYY
Address*
Street Address City State ZIP Code
Phone: (for reminders & confirmations)*
Email*
Occupation
Marital Status
- Single
- Married
- Widowed
Is Partner Supportive of Your Potential Treatment?
- Yes
- No
- Doesn’t Know I’m Here
How did you hear about us?
- Google
- Advertisement
- Brilliant Distinctions
- Groupon
- Facebook
- Instagram
- Friend/ Family
- Other
Friend/ Family Name (for referral points)*
Other (please specify)*
Flawless Reflections Body & Skin Therapy
Aesthetic and wellness treatment options available...
Which Of the Following Are Of Concern or Interest to You?
- Scars (acne or other)
- Skin Lesions
- Skin Tightening
- Sexual Enhancement
- Facial or Body Hair
- Botox/Collagen
- Non-Ablative Laser txs
- Lip Enhancement
- Stretch Marks
- Leg Veins (or face)
- Unwanted fat areas
- Skin Care Routine
- Wrinkles
- Sun Damage/Freckles
- Dark Circles/Eyes
- Hair Restoration
- Acne
- Hyper/Hypopigment
- IV Supplement/s
- Toe Fungus
- Skin Complexion/ Tone
- Hormone Replacement
What is important to you when deciding on a treatment?
- Cost
- Downtime
- # of necessary treatments
- Pain

Please fill out as completely as you are able.
All information will be held in strict confidence.
I. MEDICAL HISTORY
Are you allergic to or have you ever had a reaction to any of the following?*
- latex
- food
- fragrance
- cosmetics
- pollen
- animals
- other
Other (please specify)**
Medication Allergies (prescription or over the counter)*
Surgeries (including cosmetic)
Do you have metal implants or a pacemaker?*
- Yes
- No
Do you have any of the following?
Heart disease
- Yes
- No
Hepatitis
- Yes
- No
Epilepsy
- Yes
- No
Thyroid Condition
- Yes
- No
Hormone Imbalance
- Yes
- No
Genital Herpes
- Yes
- No
Lupus
- Yes
- No
Immune Disorder
- Yes
- No
High Blood Pressure
- Yes
- No
Cancer
- Yes
- No
Diabetes
- Yes
- No
Systemic Disease
- Yes
- No
Cold sores
- Yes
- No
Migraines
- Yes
- No
AIDS/ HIV
- Yes
- No
Other Medical problems or conditions
Do you have a history of any neurological diseases? i.e (myethenis gravis)
- Yes
- No
If yes, please specify
Please list any prescribed or over the counter medications you are currently using.

Please fill out as completely as you are able.
All information will be held in strict confidence.
II. GENERAL HEALTH QUESTIONS
Do you smoke?
- Yes
- No
Do you drink alcohol?
- Yes
- No
How often?
- Daily
- Weekly
- Monthly
Do you scar easily?
- Yes
- No
On hormone replacement therapy?
- Yes
- No
Women
Nursing?
- Yes
- No
Pregnant?
- Yes
- No

Please fill out as completely as you are able.
All information will be held in strict confidence.
III. SKIN HISTORY
Please describe your skin by checking all that apply:
- Thick
- Thin
- Saggy
- Firm
- Fine lines
- Wrinkled
- Aging
- Dry
- Normal
- Oily
- Combination
- Large Pores
- Sun Damaged/Freckles
- Uneven/Blotchy
- Active Acne
- Acne Scars/Scars
- Blackheads/Whiteheads
- Cysts/ Abscesses
- Ingrown hair
- Scaling/Flaking
- Dark spots/Patches
- Sallow (unhealthy, dull)
- Puffiness
- Rosacea
- Broken Capillaries
- Eczema or Psoriasis
- Dark Circles/Eyes
- Other
Please specify
What skin care products are you currently using?
- soap
- cleanser
- toner
- moisturizer
- masque
- mechanical exfoliator
- eye products
- sunscreen
- prescription skin care product
- acne products
- skin lighteners
Have you ever had a reaction to any of the following cosmetic ingredients?
- progesterone
- aloe vera
- hydroquinone
- benzoyl peroxide
- sulphur
- glycolic
- cortisone
- vitamin C
- sunscreens
EXFOLIATION HISTORY
Have you ever had chemical peels, laser or micro/dermabrasion?
- Yes
- No
In the last year?
- Yes
- No
Do you use Retin A, Renova, Differin, Adapalene or Retinol?
- Yes
- No
In the last 6 months?
- Yes
- No
Are you currently using products that contain the following ingredients?
- glycolic acid
- lactic acid
- exfoliating scrubs
- hydroxy acid product
- vitamin A derivatives
Check the box if yes, leave blank if no

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Our mission is to focus on each client’s individual goal of Flawless by offering state of the art technology and current techniques with highly competitive prices.

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