Treatment intake form Client information Name * First Name Last Name Date of today * MM DD YYYY Date of birth * MM DD YYYY Gender * Male Female Other Street Address * City * State * Zip Code Email * Phone Country (###) ### #### Emergency Contact Country (###) ### #### How did you hear about us? Social media Google Yelp A friend Medical History Do you have any of the following conditions? If yes, please select them: Acne Autoimmune disorders Asthma Cold sores, fever blisters COPD Cancer Diabetes Dermatitis Eczema Epilepsy Glaucoma Heart Disease Hepatitis Herpes simplex High/low blood pressure Hives Hemophilia HIV/AIDS Hyper/Hypo pigmentation Hysterectomy Keloid, hypertrophic scars Lupus Migraines Phlebitis/blood clots Psoriasis Rosacea Skin infections Seborrhea Thyroid condition Tinea Varicose veins Warts Any other condition? * List any medications you take regularly, including vitamins, herbal supplements, aspirin, topicals: * Any known allergies? * No Yes Any recent surgery, including plastic surgery? * No Yes Female clients Are you pregnant or trying to become pregnant? * Yes No Are you taking birth control pills? * Yes No Are you undergoing any hormone replacement therapy? * Yes No Your lifestyle What is your occupation? * What is your sun exposure? * Never Light Moderate Excessive Do you use sun protection (sunscreen, hats, protective clothing)? * Yes No Do you use tanning beds? * Yes No Do you smoke? * Yes No Do you drink more than 4 caffeinated beverages a day? * Yes No What is your alcohol consumption? * None Occasionally Once a week Few times a week Daily Your skin concerns Select all that apply * Acne Age spots Blackheads Broken capillaries Dark circles Dehydrated skin Dry skin Dull Skin Eczema Enlarged pores Facial hair Fine lines and wrinkles Hyperpigmentation Ingrown hairs Keratosis pilaris Melasma Milia Oily skin Premature aging Psoariasis Razor burn Rosacea Scars Skin redness Sun damage Thin skin Under-ete puffiness Uneven skin texture Uneven skin tone Whiteheads Your skin type Select all that apply * Normal skin Dry ski Oily skin Combination skin Acne-prone skin Sensitive skin Aging skin Dehydrated skin Hyperpigmented skin Sun-damaged skin Rosacea-prone skin Psoriasis-prone skin Your skin care routine Select all that apply * Eye makeup remover Foam cleanser Gel cleanser Toner Eye cream Day cream Night cream Serum Sunscreen Facial oils Mask Exfoliants Spot treatment Retinols Your skin history Have you ever had an allergic reaction to any of the following? * Alpha hydroxy acids Animals Aspirin Cosmetics Essential oils Food Fragance Iodine Latex Medication Nuts Pollen Skin products Shellfish Sunscreen Other If you checked any above, please explain * Are you currently using products containing any of the following ingredients? Any exfoliating scrub Any hydroxy acids (AHAs) Any beta hydroxy acids (BHAs) Vitamin A derivative (i.e. retinol) Renova/Retinoids Hydroquinone Any history of previous facials, microdermabrasion, peels or other treatments * How does your skin heal? Fast Slow Scars Pigments Do you get bruises easily? * Yes No Have you ever used or been prescribed any acne medication? * Yes No Have you ever received Botox, Restylane, or Collagen injections in the last 6 months? * Yes No I have read and completed this questionnaire truthfully. I understand that withholding information or providing inaccurate details about my medical history, allergies, medications, and skincare routines may lead to contraindications or adverse reactions to the treatments I undergo. I agree to inform the technician of any changes in the above information. Client signature * Date * MM DD YYYY Thank you!
