Skin Treatment Intake Form

Client's Name*

First NameLast Name

Date of Birth*

Date

If minor, Parent/Guardian Name is required

Parent’s First NameParent’s Last Name

Phone Number*

Area CodePhone Number

Email Address

example@example.com

Address

Street Address

Apartment or Suite Number

CityState

Zip Code

Occupation

Emergency Contact

First NameLast Name

Emergency Contact's Phone Number

Area CodePhone Number

Are you under the care of a physician?*

YesNo

Primary Physician

First NameLast Name

Please select if you have experienced or are experiencing the following conditions:

For Rezenerate Nanoneedling Facials, select if you have any of the following:

For Electrotherapy Direct High Frequency treatment, select if you have any of the following:

Any known allergies?

List any medications or supplements you’re taking:

What concerns you most about the overall appearance of your skin? (check all that apply)

If you could improve your skin, what would you like to see?

How would you describe your skin?

How do you heal after an acne breakout, cut or scratch?

No ScarRedBrown (PIH)

Do you smoke?

YesNo

What skin care products do you use on a regular basis?

In the last 5 days, have you used any topical and/or oral prescription strength medications such as: Tretinoin, Retin-A, Differin, Tazorac, Avage, EpiDuo, or Ziana?

YesNoOther

In the last 7 days, have you received any Botox, injectables or dermal fillers?

YesNoOther

Have you ever received chemical peels, laser services, microneedling/ nanoneedling, or microdermabrasion treatments?

Yes, within the last monthYes, within the last 2-3 monthsNo

In the last 6 months, have you been on or undergone?

AccutaneCosmetic SurgeryLaser TreatmentChemotherapy or Radiation

What beauty or cosmetic products are you currently using?

Are you taking any medications that are related to cosmetic or skin improvement?

Are you taking birth control?

YesNo

Are you pregnant or breastfeeding?

YesNo

Client services and chart information are confidential. Written authorization is required from you to release any information.
Your scheduled session is set aside for you. We do not double book appointments.
Please reschedule your session if you are more than 15 minutes late.
All treatments, services and products are non-refundable. Rescheduling requests should be made at least 24-hours prior to your scheduled appointment time. Booking/retainer fee of 50% of the service price is due at the initial booking, is non-refundable, and will go towards the balance of your services. Remaining balance will be due once services are provided. Please call at least 48-hours prior to your appointment should you need to cancel to avoid the booking/retainer fee, 50% of the listed menu price.
You will be draped and at no time will genitalia or breast tissue be exposed.
You will have a consultation with your skin care specialist to discuss your session.
After your skin care specialist has left the room, you may disrobe to your comfort level.
Client understands that the skin care specialist or them may end the session at any time for any reason.
Inappropriate behavior is not tolerated and may be prosecuted to the full extent of the law.
Right to Refuse Service: The licensed professionals at Neblibana reserve the right to refuse services at their discretion and dismiss disruptive and/or abusive clients when necessary.

I understand that my data will be strictly confidential. Neblibana LLC does not sell, share, or resell information.

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 (SPF 30), 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 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 not part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given in this form are true and accurate and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

I release Neblibana LLC and its staff of any liability associated with any injuries and/or current and future conditions resulting from the skin care procedures or products.

By my electronic signature below, I agree to the skin treatment policies and client agreement above.

Client Signature*

If minor, Parent/Guardian signature is required

Date Signed*

Date

How did you find out about us?

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Neblibana

Medical Conditions

About Your Skin

Female Clients

Treatment Policies

Client Agreement