Returning Client Health History UpdatePlease enable JavaScript in your browser to complete this form.Date *Name *AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMobile Phone *OK to receive text messages on this phone *YesNoEmail *Have your received your COVID vaccination shots? *YesNoAny Changes to your Health History? (copy) *YesNoNo Changes to My Health HistoryI have confirmed that there have been no changes to my health history and I have not started any new medications since my last visit. 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 my skin care therapist of my current medical or health conditions and to update this history. The treatments I receive at Oly Skin & Wax are voluntary and I release Melissa Williams from liability and assume full responsibility thereof.Client SignatureClear SignatureDateNew Health History Information/Update What are you being treated for?New Medications: Client SignatureClear SignatureDateMessageSubmit