CHRYSALIS New Client intake form

Comprehensive Skin Scare Program
By completing this client profile, you will assist us in the evaluation of your skin condition. The information you provide will be used to determine what factors may be affecting your skin SO that we may recommend the proper care. All information is private and not shared with others.
Name

First Name Last Name
Email
example@example.com
Date

Month Day Year
Date
Address

Address

Street Address Line 2

City State

Zip
DOB
Age
Cell Phone
Home Phone
Work phone
Emergency Contact/Phone
How did you hear about us?
Name:
Occupation
Are you presently under a doctors care for any reason?

Yes No
If Yes, please explain
Women: Are you Pregnant?

Yes No
What medications do you take on a regular basis?
Please list ALL allergies:
Skin Type:

Mature Sensitive Dry Oily Combination Very Sensitive/Rosacea Ance/Problematic
What are your skin concerns: (check all that apply)

Sun Damage Loss of Elasticity Scars Scars Sensitivity Dehydration Uneven Skin Texture Rosacea Fine Lines/Wrinkles Blackheads Whiteheads Acne/Problematic Dilated Capillaries Hyperpigmentation Enlarged Pores Acne Scarring
Within the last month, have you taken or used any of the following?

Retin A/ Renova Accutane Glycolic Acid/ Alpha Hydroxy Acid Antibiotics Blood Thinners Oral Contraceptives
Have you had any of the following?(please check all that apply)

Cosmetic Surgery Laser Resurfacing Dermal Fillers Botox Chemical Peels IPL/PhotoFacial Skin Cancer Hepatitis Dermatitis Keloid Scarring
Do you smoke?

Yes No
Do you take supplements?

Yes No
Do you wear sunscreen daily?

Yes No
Are currently having facials?

Yes No
How often?
How is your general health?

Excellent Good Fair Poor
What is your stress level?

High Moderate Low
What is your ethnic background?
When exposed to the sun, do you usually

Always burn, never tan Burn easily, tan poorly Tan after initial burn Burn minimally, tan easily Rarely burn, tan darkly easily Never burn, always tan darkly
Is there anything else we should know that may affect your treatment?
What are your specific Goals and Expectations for improvement?
What is your specific concern about your skin?
How long have you noticed your condition?
Is this an ongoing or temporary condition?
In what time frame do you expect to reach your goals?
Have you ever received a spa skin care treatment?
What were the results?
In what time frame do you expect to reach your goals? Have you ever received a spa skin care treatment?
Chrysalis Cancellation Agreement

We realize that circumstances may, on occasion, cause you to change or reschedule your appointment. To avoid cancellation charges, please notify us of any changes or cancellations to your appointment at least 24 hours in advance. Changes or cancellations made less than 24 hours in advance will incur a charge of 50% of the scheduled treatment(s) and/or service(s No-shows and cancellations within 4 hours will be charged 100% of the scheduled treatment(s) and/or service(s
Signature (Guest)

Clear
Date

Month Day Year
Date
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