Name
*
First Name
Last Name
Pronouns
Age
*
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Preferred method of contact
*
Call
Text
Email
Any of the above
Medications
*
Check All that Apply
Please list medications and supplements you are currently taking (or write "none")
*
Medical History
*
Please check all that apply
Are you currently under a dermatologist's or other physician's care?
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Yes
No
If yes, doctor's name:
Have you ever had any reaction to any products or anything you have put on your face?
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If yes, what products?
Please check any of these you are allergic to:
*
List any other allergies:
Do you smoke?
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Yes
No
Do you use fabric softener or fabric softener sheets in the dryer?
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Yes
No
Do you swim in a chlorinated pool on a regular basis?
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Yes
No
Do you work around chemicals, tars, grease or inks?
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Yes
No
What is your job/occupation/student?
*
Do you work nights?
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Yes
No
Are you currently under a lot of stress? (common stress = job loss, new job, wedding, romantic breakup, death in the family or friend, graduation, difficult home life, heavily scheduled, long commute, anxiety/depression)
*
Yes
No
Do you use Birth Control Pills, Shots, or use an IUD?
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Yes
No
If yes, which form of birth control do you use?
What is the brand of your pill/IUD?
Do you shave or dermaplane your face?
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Yes
No
Dietary Considerations
*
Do you consume any of the following foods?
Do you have food sensitivities?
Skincare Products or Makeup You are Currently Using
*
Other Treatments: What else have you done for your skin in the last 90 days?
*
Mansfield Hollow Skincare, LLC Cancellation Policy and Appointment Etiquette
*
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 the Policies of MHS by typing your name:
*
First Name
Last Name
