The Brown Skin Co: Confidential Pre-Assessment
This form is required for all customers, regardless of service, when booking an appointment at The Brown Skin Co. Please answer to the best of your ability, should you need any assistance do not hesitate to contact me. All answers are confidential and will only be seen by me. After this appointment, you do not have to answer these questions again, however, if your health changes in any way (skin changes, pregnancy, cancer, etc.), as well as any changes to your routine, please update me via email or text before your next appointment. This is for your safety and to provide the best service possible. Additionally, please be sure you have read all policies as booking an appointment confirms you have done so. Thank you! 
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Full Legal Name *
Date of Birth (Month/Year)
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Email you used to book
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Preferred Pronouns
Will this be your first time ever receiving this service? If yes, please specify which service if receiving multiple.
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Have you been under the care of a physician, dermatologist, or another medical professional, or had any recent surgery within the past year? If yes, please explain.
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Please include any additional health information (foreign objects/pacemaker, Autism, PCOS, Lupus, HIV/AIDS, etc.),  including any known allergies or medications (orally & topically) you take regularly.
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Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA, Salicylic Acid, any acne products or Retinol/vitamin A derivative products? If yes, please list product & last date used. (Discontinue any topical medications like Differin or Tret 7 days before & 7 days after treatment)
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Are you pregnant and/or lactating?
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Do you have a history of acne? If yes, please include any important details.
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Do you have sensitive skin? Have you ever experienced any adverse reactions to skincare products or services? If so, what kind of reaction?
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To the best of your ability, please briefly describe how your skin feels/reacts on a day-to-day basis. *Type N/A if waxing only*
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Please list all skin care products, if any, currently being used with their actual names, if possible. If, waxing please include any products you use for bikini care.
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How did you hear about The Brown Skin Co.? (Google, IG, referral, etc.) Please include the name of the person who referred you, if applicable. 
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If you're following me on Instagram (@thebrownskinco) please include your username, I'd love to follow you back!
Media Disclaimer: Video and/or photography may be taken tastefully and with discretion for insurance and documentation requirements (skincare treatments primarily) and occasionally for marketing and content purposes. You agree to waive your rights to this content, however, I am happy to share any media with you for your personal use.  *
Required
Consent to Treatment: I have voluntarily booked this service and recognize there are no guaranteed results. I understand that results are dependent upon age, skin condition, consistency, and lifestyle. I have also, to the best of my knowledge, accurately answered the skin assessment questions above.

I agree to not hold The Brown Skin Co., LLC. (or Trachouse LLC.) responsible for personal loss or injury due to theft, burglary or negligence or for any of my conditions that were present, but not disclosed at the time of the skincare procedure and any results that may occur as a result. I agree to update my esthetician before my next appointment if the status of my skin, home care routine, or health changes.

Waxing: I understand waxing has the potential to cause slight tearing, redness, hyperpigmentation, pimples, or a flare-up of Herpes, Staph/MRSA, or any other STI/STDs that may have been dormant previously. I understand I may carry herpes and/or Staph/MRSA without any physical symptoms or medical diagnosis, and that the waxing service does not allow any opportunity to contract these conditions from my esthetician.

Please type your full legal name and date to confirm you have read and understand.
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Do you agree to be added to my email and/or SMS marketing list? This is the best way to stay updated on important booking info, sales, exclusive deals & the occasional message blast. I promise not to spam you, unsubscribe anytime.
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