Stacy Kaine Intake Form

Stacy Kaine Intake Form
Date

MonthDayYear
Date
First name
Last Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
How did you hear about us?
How did you hear about us?

Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?

YESNo
Have you experiences any of these health conditions in the past or present?

Hormone ImbalanceCancer/Systemic diseaseHigh blood pressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpilepsy/SeizuresCold soresHIV/AIDSLupusDepression/ AnxietyHeadaches/ MigranesNoneOther
Any known allergies?

AsprinLatexFruitsShellfishLidocaneFragrance/essentials oilsTree NutsDairySunscreenPollenNoneOther
List medications/ Supplements you are currently taking
Have you ever received any Botox or Fillers? If so, where and when?
Have you ever experienced claustrophobia

YESNO
Please list your stress level

LowMediumHighNone
Your Skin
What are your skin concerns?
What would you say your skin type is?

Normal (no visible blemishes, fine pores,smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a daily basis?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye creamMoisturizerSPFVitamin A (retinol)
Do you experience any breakouts or acne?

YESNO
Have you been diagnosed with eczema, psoriasis, or rosacea?

YESNO
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/ Electolysis
Do you currently use:

AccutaneRetin-APrescribed topical cream
Please specify product or type, if you answered YES to the question above.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YESNO
Do you?

Wear contact lensesHave a pacemakerHave metal implantsSmokeConsume AlcoholConsume CaffeineFrequent tanning beds
Female Clients
Are you taking birth control?

YESNO
Are you pregnant or breast-feeding?

YESNO
I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is a strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.
I release Stacy Kaine and its staff of any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.
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Stacy Kaine Intake Form

Your Medical History

Your Skin

Female Clients