Client Profile Card
All information collected for the benefit of treatments
Last Name *
Your answer
First Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone number *
Your answer
Are you currently or have you been under the care of a physician in the past year? *
If yes, please provide details:
Your answer
List any health problems (Cancer, Diabetes, Hormone Imbalance, Diet etc.):
Your answer
List all medications, viatamins and health supplements:
Your answer
Any known allergies? *
If yes, please provide details:
Your answer
Please select yes or no to the following: *
No
Yes
Pregnant/Lactating
Retin A
Acutane
Do you have any metal implants?
Epilepsy
Pacemaker
Heart disease
High blood pressure
Thyroid disease
Steriods
Open wounds
Plastic Surgery
Please select yes or no to the following *
No
Yes
Blush easily
Sunburn easily
Sinus problems
Keloid scar easily
Additional notes
Your answer
Ethnicity *
Required
Client Consent to have recommend treatment *
Email Address *
Your answer
Date *
MM
/
DD
/
YYYY
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This form was created inside of Legends Barbershop.