ME Beauty Republic.™

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Have you ever had a reaction after waxing

If yes, Please explain

Yes

No

Have you been under the care of a physician, dermatologist or other medical professional within the past year? *

if yes, please explain

No

Yes

Any Recent surgery, including plastic surgery, and c-section *

If yes, please explain

No

Yes

Any skin cancer

If yes, please explain

No

Yes

Are you on any medications *

If yes, please explain

No

Yes

Are you allergic to anything

if yes, please explain

No

Yes

Are you pregnant?

No

Yes

Do you have a sexually transmitted infection? *

If yes, please explain

No

Yes

Have you been exposed to the sun or use a tanning bed in the last 48 hours? *

No

Yes

Are you using Retin-A®, Accutane®, Alpha Hydroxy, Tetracycline or any other acne/skin medications or products? *

if yes, please list the medications

No

Yes

Have you received any Botox® or Derma-brasion treatments recently? *

If yes, please explain

No

Yes

Do you have diabetes, phlebitis, eczema, or psoriasis? *

If yes, please explain

No

Yes

Is there anything else that I need to know to better serve you?

If yes, please explain

No

Yes

THE LEGAL STUFF *

THE LEGAL STUFF I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform Tiffany of ME Beauty, LLC of my current medical or health conditions and to update this history. The treatment I receive here are voluntary and I release ME Beauty, LLC and or Tiffany R. Piggee' from liability and assume full responsibility thereof.

No

Yes