Treatment Intake Form

Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Date

Month Day Year
Date
How did you hear about us?
List any medications, supplements, or herbal remedies you currently take: *
Please list allergies or sensitivities: *
Please list Injuries or surgeries: *
Have you ever received professional skin care treatments?
What is your daily skin care regimen?
What are your current skin condition concerns? *

Fine Lines & Wrinkles Glycation/Deep Wrinkles Sun Spots Melasma Uneven Skin Tone Sagging/Loss of Collagen Texture Breakouts Acne Infammation/Redness Dryness Oily Dullness Blackheads & Whiteheads Pore Size Dark Circles Puffiness Other
What do you consider your skin type? *

Normal Oily Acne Dry Aging Combination Sensitive Rosacea Other
What is your #1 goal for this session.
Please check all that apply. *

Pregnant Diabetes Jaw Pain / Clenching/ Grinding Claustrophobic Metal Implants Experience cold sore/fever blisters Ecezema Psoriasis Dermatitis Other Skin Condition(s) Surgeries within the last 30 days? Used Retin -A, Tazarac, Azlex, Differin, Renova and/or Tretinoin within the past 10 days? Used Accutane within the past 12 months? Used Botox and/or Fillers within the last 7 days? Used AHAs (Alpha Hydroxy Acids) like Glycolic within in the last 7 days? Had hair removal services like laser treatments, waxing or electrolysis in the last 7 days? Went tanning and/or had extended exposure to the sun in the last 7 days? None
You May Experience:

Break-outs: We cannot cause any breakouts to occur, however if there is
congestion or trapped sebum plugs the treatment may release these from the
epidermis and result in a superficial break out.

Dry, Tight Patches: This is where dead protein cells are still attached to the
epidermis and has not been released.

Underlying Pigment (due to the aging process), May Move To The
Surface: This is due to the hydrolyzation of dead protein cells. Making the area look more visible to the eye.

Redness, Heat and/or Sensitivity: For the first or second day (more so on the
stronger treatments). We are activating the skin to function normally so it may feel different (as in different texture) whilst undergoing treatment.

I understand these contraindications are temporary and often accompany a successful treatment over a period of time.

Should none of the above contraindications occur, I understand that this is not a sign the treatment is not working but rather I am in excellent health and respond to organic material well.
Please Check: *

I Understand
Photo/Video Release:

I understand that the taking of before and after photographs of the procedure(s) is a condition my treatment(s) and must be done.

I give the studio, permission to use my name, likeness, image and/or appearance as such may be embodied in any pictures, photos, video recordings, digital images, and the like, taken or made during my procedures.

I agree that the studio has complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose. These uses include, but are not limited to illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release the studio and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.
Please select: *
General Release:

I have completed this form to the best of my ability and knowledge and agree to inform Bondi Skin Therapy of any changes in the above information.

I have been informed of and understand the contraindications to the requested treatments and agree I do not have any condition(s) that would make the requested treatment unsuitable.

I will inform Bondi Skin Therapy of any discomfort I may experience at any time during my treatment to all them to adjust accordingly.

I agree to waive all liabilities toward my esthetician and Bondi Skin Therapy for any injury or damages incurred due to any misrepresentation of my health history.
Signature *

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