New Client Intake Form


Please answer the following questions so that we may have a better understanding of your general health and lifestyle, thereby enabling us to accurately analyze and assess your skin-care needs.

Date *
Date
Name *
Name
Birth Date *
Birth Date
Address *
Address
Cell Phone
Cell Phone
Phone
Phone
Phone *
Phone
Your Health
Have you been under the care of a physician, dermatologist or other medical professional within the past year? *
Any recent surgery, including plastic surgery? *
Any skin cancer? *
Have you had any piercings, tattoos, or permanent cosmetics? *
Have you ever had a body spa treatment before? *
Have you had any of these health conditions in the past or present? *
(Please check all that apply and provide additional information in the space provided)
Has your physician discussed concerns about raising your body temperature? *
Do you smoke? *
Do you follow a restricted diet? *
Do you follow a regular exercise program? *
What is your stress level? *
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products? *
Have you used any of these products in the last 3 months?
Have you used an acne medication? *
Do you form thick or raised scars from cuts or burns? *
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *
Water
Caffeine
Alcohol
Do you experience any problems sleeping? *
Do you wear contact lenses? *
Have you been exposed to the sun or used a tanning bed in the last 48 hours?
How frequently are you exposed to the sun or use a tanning bed? *
Do you have any metal implants or wear a pacemaker? *
Have you ever experienced claustrophobia? *
Do you suffer from sinus problems? *
Have you ever had an adverse reaction after using any skin care product? *
Please check any that apply
Have you ever had an allergic reaction to any of the following? *
Please check any that apply
Female Clients Only:
Are you taking oral contraceptives? *
Any recent changes to or from your contraceptive treatment? *
Are you pregnant or trying to become pregnant? *
Are you lactating? *
Any menopause problems? *
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 the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. *
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 the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.