Returning Client Health History Update

Date *

Name *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone *

OK to receive text messages on this phone *

Yes
No

Email *

Have your received your COVID vaccination shots? *

Yes
No

Any Changes to your Health History? (copy) *

Yes
No

No Changes to My Health History

I 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 Signature

Date

New Health History Information/Update

What are you being treated for?

New Medications:

Client Signature

Date

Melissa Williams

Melissa Williams

Melissa Williams

Returning Client Health History Update

Melissa Williams, Master Esthetician