Skin Intake Form

Name

First NameLast Name

Date of birth

Date

How did you here about Skin By ASAO?

What are your main skin concerns?

List any prescribed medications or topical treatments (Retinol or Tretinoin) you're currently taking:

Check all that apply:

Have you ever had any of the following: chemical peel, microdermabrasion, dermaplane, botox, fillers, facial laser resurfacing, permanent makeup, if so which one and how long ago?

Allergies:

Are you currently pregnant or planning to be?

List your skincare routine:

Do you wear SPF daily?

If you had to describe your skin it would be…

Do you consent to having a photo/video taken for a before and after (To help track your skin care process as well as being on social media)

For Chemical Peels

I understand that:

This is an exfoliation treatment and may experience but not limited to skin sensitivities, redness, flaking, tightness, lightening, stinging to the skin
If I have any concerns after this treatment I will contact my esthitician as soon as possible
I agree to adhere to all the safety precautions and home skin care regimine recommended to me by my esthitician, including wearing SPF after my treatment
I will not use any products containing AHA's or BHA's 48 hours before and after this treatment
I will not receive a chemical peel 3 weeks prior to my appointment as well as 3 weeks after
I understand that I may need more than one treatment to see results and results vary on skin type, after care, and degree of sun damage

For Dermaplaning

I understand that during this procedure

My esthietician is using a surgical blade and this could cause minor cuts
This is an advanced exfoliation treatment which gets rid of dead skin as well as vellus hairs (peach fuzz)
I will not exfolitate 48 hours before and after this treatment
My skin may become sensitive or slightly red for a few hours
I will be denied this treatment if I have inflamed acne, rosacea, and any appearance of burns, rashes, or infections

I agree that

I have answered the above to the best of my knowledge
I have read and understand the risks of certain treatments and agree to my esthetician to preform on me
Per policy if I need to cancel or reschedule I must do so at least 24 hours prior to my scheduled appointment. If I fail to do so I will be charged 50% of my service with the card on file.
If I am late to my appointment my time allotted will not be extended, and if i am more than 15 minutes late I will be canceled, and the card on file will be charged 50% of the service scheduled, if my card on file declines I will not be allowed to book until fees are paid.

By signing this form I understand any and all risks that may occur during this treatment as well as abide to the policies.

Signature