Facial Intake Form

Facial Intake Form
Appointment date

Month Day Year
Date
Appointment time
AGE

PHONE
D.O.B.
AGE
EMAIL / NEWSLETTER
Would you like to be added to our

subscriber list in order to receive

information about upcoming dicounts,
promotions, contests etc.?

YES! Sign me up! No, thanks
Any personal or family history of cancer?
Do you take care of your skin at home?

Never Moderate Yes No Light Excessive Yes No Sunbath Self-tanning Tanning bed Nothing
How do you prefer to get a skin tone?

How would you describe your skin?
Please, describe
Is it your first skin care treatment?

Normal to dry Normal to oily Extremely oily Extremely dry Yes No Acne Combination Flakiness Redness Tightness Excessive oily shine during the day
What have you liked about previous
What have you liked about previous treatment?
What type of foundation do you wear?

Yes No Liquid Cream
What is your daily amount
Do you have any from listed below:
How does your skin heal?

Powder None Recent operations
Do you bruise easily?

Fast Scars Epilepsy Pigments Heals poorly Heart condition Diabetes Skin cancer Yes No Allergy to aspirin Skin diseases
Have you used Accutane in the past 12 months?

Are you currently on any medications?
If yes, please, describe

Yes No Yes No
If yes, please, describe
Have you used Retin- A in the past

Have you used any oral/ topical skin

medications in the past 6 months?

Do you have allerigies to latex?
Do you have allerigies to any skin care products?

Yes No Pregnant Yes No Trying to become pregnant Not pregnant Taking oral contraceptives Taking hormone replacements Yes No Yes No Yes No
Do you suffer from ingrown facial hair?
If yes, please, describe
Experience razor burn?

Yes No
Please, circle if you are you affected by or having any of the following:

hysterectomy sinus problems cardiac problems

herpes high blood pressure epilepsy pace maker

pins or plates headaches-chronic lupus metal bone

How would you describe your overall health?
Have you ever had reaction to

Excellent Good Fair Poor Cosmetics Fragrance Medication Other
This form is completely confidential. Completion of form gives the general state of health and assists our specialist in directing a customized course of treatment for you. The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any any existing or past health conditions.
date

Month Day Year
Date
date

Month Day Year
Date
Skin Care Consultation Form
AGE

PHONE
-2-29
AGE
Address

ADDRESS

Street Address Line 2

CITY
Lifestyle

Active Sedentary
Any cosmetic surgery/non-surgery:
When?
SKIN ANALYSIS
MEDICATIONS
Skin type

Normal Dry Combination Oily
List mediactions in the last 30 days (pills, birth

control, vitamins, herbal supplies, etc:
Skin sensitivity

Normal Sensitive Hypersensitive
List mediactions in the last 30 days (pills, birth control, vitamins, herbal supplies, etc.)
ALLERGIES
Reaction allergies
Lines

Fine lines None
Skin allergies
Acne

Wrinkles in motion No Yes I II III IV Fine Dilated Comodones Milia
TREATMENT PLAN
Client After-Treatment
Perfect Routine
CLEANSER
TONER
MOISTURIZER
SUNSCREEN
Appointment Cancellation Policy

We strive to render excellent care to you and the rest of our clients. Your care and treatment is a priority for us. We also ask that you respect your therapist's time and expertise as well. In an attempt to be consistent with this, we have a Cancellation Policy that allows us to schedule appointments for our clients, with respect for your time, the next client's time, and the therapist time. Our policy is as follows: We request that you givein the event that you cannot make it to your scheduled appointment. If the client misses an appointment without contacting us, it is considered a missed or "No Show' appoinment. A fee as shown below will be charged to your credit card, depending on the type appointment missed. Additionally, if a client is more than 15 minutes late for an appointemnt, it will be considered as No Show' appointment, and that appointment will be rescheduled. Also, if you miss more than 3 appointments, we reserve the right to discharge you from the practice for failing to follow treatment recommendations. If you have questions regarding this policy. please let us know, and we will be happy to clarify our policy for you.

I have read and understand the Appointment Cancellation Policy, and I agree to be bound by its terms. I am aware that my credit card will be charged for the missed appointment, and I agree to this terms.
Cancellation Policy.
Client Signature Receptionist Signature
Date

Month Day Year
Date
NUMBER
EXP. DATE

Month Day Year
Date
Treatment
Consent Form
I hereby consent to and authorize Emmie
(esthetician)
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards Emmie involved, by (esthetician)
(esthetician)
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post- treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Client name
Client singature
Date

Month Day Year
Date
E.Montgomery
Esthetician name
Date

Month Day Year
Date
Should be Empty:

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Facial Intake Form

EMAIL / NEWSLETTER

Skin Care Consultation Form

SKIN ANALYSIS

MEDICATIONS

ALLERGIES

Client After-Treatment

Perfect Routine

CLEANSER

TONER

MOISTURIZER

SUNSCREEN

Consent Form

E.Montgomery