Acne Intake Form

Date*

Date

Name*

First NameLast Name

Date of Birth*

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?*

If referred, by who?

Medications

	When	How Long
Antibiotics
Accutane
Benzoyl Peroxide
Retin A
Tazorac
Differin
Azelex
Avita
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Androstendione
Testosterone
Progesterone
Thyroid
Gonadotrophin
Danzol
Cyclosporin
Lithium
Isoniazid
Immuran
Disulfuram
Dilantin/Tegretol
Steroids
Marijuana
Cocaine/Speed

Medication Not listed

Medical History

	Please Check All that Apply
Herpes Simplex
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Ovary(ies) Removed
Pace Maker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body

Are you under a Dermatologist or other Physician's care?

If yes, Please note Doctor's name

Have you ever had any reaction to any products or anythin g you have put on your face?

If yes, what products?

Please check any of these you are ALLERGIC to

SulfurAspirinLatexOther

Do you Smoke

How much water do you drink daily?

Do you drink Alcohol?

If so, how often in a week and what type of alcohol?

What is your sugar intake like? (sugary drinks, soda, candy, etc)

Do you use fabric softeners in the dryer?

Do you swim in a chlorinated Pool?

Do you work around chemicals, tars, oils, grease, or inks?

Occupation

Do you work nights?

Are you currently under a lot of stress?

*WOMEN: Do you use birth control pills, shots, or use an IUD?

If so, which brand do you use?

Are you pregnant or nursing?

*Do you shave your face or do hair removal on the face?

If so, what method?

DIET- Do you consume the following?

	Please check all that apply	How often in a week?
Fast Food
Processed Food
Salty Snacks
Milk/Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy-tofu, tempeh, edamame, soy sauce
Vitamins
Seafood

Products you are Currently Using

	Please list Product Names
Cleanser
Toner
Serum
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliant (Acids, Serums, Scrubs)
Acne Medications
Other

What type of makeup remover do you use?

Other Treatments: What have you had done to your skin in the past 90 Days?

	When?	Where?
Chemical Peels
Microdermabrasion
Dermabrasion
Laser Hair removal
Laser Rejuvenation/ Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other

TERMS AND CONDITIONS:

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facial services.
2) I understand that the esthetician does not diagnose illnesses or injuries,
or prescribe medications.
3) I have clearance from my physician to receive facials.
4) I understand the risks associated with facials that include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

I, therefore, release Lauren Jeong Esthetics and the esthetician from all liability concerning these injuries that may occur during the treatment session.
6) I understand the importance of informing my esthetician of all medical
conditions and medications I am taking, and to let the esthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
7) I understand that it is my responsibility to inform my esthetician of any
discomfort I may feel during the session so he/she may adjust
accordingly.
8) I understand that I or the esthetician may terminate the session at any
time.
9) I have been given a chance to ask questions about the session
and my questions have been answered.

Signature*

Lauren Jeong Esthetics

Lifestyle Considerations