Confidential Plasma Lift Intake Supplement

Confidential Plasma Lift Intake Supplement
Welcome! This intake form is a supplement to the Confidential Skincare Intake Form. Both forms contain important information for safe consideration of your interest in the Plasma Lift Treatment! If you are a longtime Spa Aeon skincare client but are new to Plasma Lifting, please fill out a fresh copy of the regular Confidential Skincare Intake Form so we can properly plan for your home skincare use before and after this treatment.

Here you will find many sensitive but important questions, so please fill it out privately, fully, and at a time when you have all of your skincare products, medications, and supplements at hand, and be sure to keep scrolling until you have answered everything, signed, and clicked Submit. The health and lifestyle topics addressed herein ALL have the potential for affecting your skin or causing interactions with aspects of your treatment at Spa Aeon... if they didn't, they would not be included.

Your Health Intake and Treatment Notes are held in the strictest confidence.
Full Name *

First Name Last Name
E-mail *
Phone Number *

Area Code Phone Number
Birthday

Month Day Year
Referred by *
Does your job require you to work outdoors?

Yes No
What would you like to achieve from your Plasma Lift Treatment?
Have you ever had a skincare treatment before? Choose the most recent:

Yes, only at Spa Aeon Yes, at Spa Aeon and elsewhere Yes, but never at Spa Aeon Never
Which of the following best describes your complexion?

I Very Fair: Always burns easily, cannot tan II Fair: Usually burns, sometimes tans III Medium: Sometimes burns, usually tans IV Olive: Never burns, always tans V Brown: Never burns, always tans VI Black: Never burns, always tans
Topical Retinoids are a category of anti-aging & anti-acne prescription and non-prescription skincare products that use a variety of different molecular forms of Vitamin A to treat the skin. Retinoids may include: Retin-A, Renova, Tretinoin, Differin, Green Cream, Tazorac, Retinol, Retinyl Propionate, Vitamin A, or Beta Carotene. Topical Retinoid treatment may make up an important part of your Spa Aeon treatment plan. It is also important that we know beforehand if you are already using them.
Do you use Topical Retinoids?

Yes No Not Sure
If so, which one and how often?
Certain other topical ingredients are considered highly active and may impact the best choice of treatment for you at Spa Aeon. You may have already covered these above, but just to be sure, are you currently using any of the following on your skin, even occasionally:

Topical Vitamin C Alpha Hydroxy Acids (may be listed as Glycolic Acid or AHA) Beta Hydroxy Acid (also known as Salicylic Acid or BHA) Hydroquinone (a skin lightening agent) Topical Antibiotics for acne Hydrocortisone or other steroid creams Benzoyl Peroxide
List all current medications here:
List all current supplements here:
Have you used the Prescription Oral Acne Medication ACCUTANE or any other brand of Prescription Oral ISOTRETINOIN in the past 6 months?

Yes Not Sure No
Past and present UV exposure habits impact safe treatment. Please check all statements that apply to you:

I sunbathe I use tanning beds I'm outside a lot In the past I tanned I wear daily SPF I avoid the sun I wear sunglasses I wear hats

When do you use the following types of sun protection?

	Never	Sometimes	Most Days	Every Day	Outdoor Activities
SPF 4-15 Tanning Products
SPF 15 or 20 Makeup
SPF 15 or 20 Moisturizer or Lotion
SPF 30 to 50 Sunscreen
SPF 50 or Higher Sunscreen

Hormonal factors have a substantial impact on skin condition and must be considered in determining safe and effective skincare treatments. Please check any of the following that apply to you:

Pregnancy Nursing Hormonal Contraceptives Discontinued Hormonal Medication Menopause Hormone Replacement Therapy Polycystic Ovarian Syndrome Partial or Full Hysterectomy Hashimoto's or other Endocrine Disorders Miscarriage Puberty Hormone Changes
Type of Hormonal Contraceptive or HRT used:
Please check any of the following that you have had in the past 6 months:

Botox Filler injections Cosmetic Surgery Laser treatments Chemical peeling Radio Frequency or Ultrasound tightening
If you checked any of the cosmetic procedures above, please list the date(s) of administration and any complications you experienced:
Do you have any skin conditions, skin diseases, skin lesions, immune disorders, active infections, blood clots, bleeding problems, diabetes, lupus, current fever blisters/cold sores, or any other conditions that would limit your eligibility for skin care and waxing treatments? If yes, please explain:
Are you pregnant, nursing, or trying to become pregnant?

Yes No
Do you have any additional concerns that were not addressed in this Health Intake? If so, please explain:
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 irritations to the skin from the treatments received. I am aware that it is my responsibility to inform the Esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Spa Aeon, Aeon Aesthetics, LLC, Christine Giustra, and our employees, contractors, and agents from liability and assume full responsibility thereof. I understand that requests to cancel or reschedule appointments are gladly accommodated with 24 hours notice and that short-notice cancellations/reschedule requests (less than 24 hours) and no-shows will be charged.
Signature:

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spaaeon@gmail.com
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