General Skincare Client Intake Form

Answer YES or NO. Give more information under DETAILS if necessary*

	YES	NO	Details
Do you use Retin-A, Renova, or Retinol/Vit A derivative product?
Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hrs?
Are you currently taking Accutance or have taken it in the past
Have you used other acne medication?
Are you exposed to the sun on a daily basis or do you use a tanning bed?
Are you taking hormonal contraceptives?
Are you pregnant or trying to become pregnant?
If pregnant, are you nursing?
Experiencing any monopause problems?
Are you undergoing any hormone replacement therapy or cancer treatments?

We want to know what skincare products your are currently using

Select areas of concern

Breakouts/AcneBlackheads/WhiteheadsExcessive oil/ShineRedness/RuddinessSun damageUneven skin toneSun spots/Brown spotsWrinkles/Fine linesDull/Dry skinDark circles around the eyePuffiness around the eyeFine linesOther
Have you ever had any allergic reaction to the following:

CosmeticsMedicineShellfishPollenFragranceSunscreensCollagenLatexOther
I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritations from treatments received. The skin care treatments I receive from YOURSPA MJ, LLC or YOURSPA MJJ, LLC are voluntary and release the said company/business entity from liability and assume full responsibility thereof.
NOTE: For cancellation, kindly inform us 24 hrs prior to your appointment. Failure to do so will result in a $20.00 penalty which will be charged on your next visit. Clients who come late to their appointment will forfeit the full time allotted of their service. In addition, clients who are 30 minutes (or more) late will be asked to reschedule and will be charged a $20 fee on their next visit. We have these policies in place in order for our valued customers to be able to enjoy the full service, as well as in consideration to everyone's time.
Please sign*

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