New Client Intake Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Area Code
Phone Number
4
How did you hear about Live by Skin?* This field is required.If you were referred by a client, please list their name! :)
5
Do you experience any of the following skin conditions?* This field is required.Please check all skin conditions that you are working on.
Inflamed Acne (red blemishes with or without a "head")
Non-Inflamed Acne (blackheads, congestion, whiteheads)
Dehydration
Excess Oil
Hyperpigmentation
Acne Scars (textural)
Acne Scars (post inflammatory hyperpigmentation)
Rosacea
Acne Rosacea
Dehydration
Other
6
What are your goals for your skin? What would you like to focus on in your treatment?* This field is required.
7
Please list all allergies.* This field is required.This includes food, supplement, medications, ingredient, and substance allergies. You may write n/a if you have no known allergies.
Huge
Large
Normal
Small
Ok
Ok
8
Have you ever had an adverse reaction to a skincare product or treatment?* This field is required.
YESNO
9
If "yes" please explain.* This field is required.(Write n/a if you answered no.)
10
Please list all medications and supplements you are currently taking.* This field is required.Oral and topical.
11
Have you had botox or filler within the past 14 days?* This field is required.
YESNO
12
Have you had microblading, a microblading touch up, or any cosmetic tattooing within the past 4 weeks?* This field is required.
YESNO
13
Have you had any professional facial treatments within the past 4 weeks?* This field is required.This includes facials, peels, microneedling, any sort of laser, or aesthetic treatment.
YESNO
14
Do you have any of the following conditions? If yes, please select them:
Cancer
Hypotension
Metal Implants
Hypertension
Pace Maker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV/AIDS
Hepatitis A/B/C
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Menopause
Circulation Disorder
Herpes/Cold Sores
Allergies (to anything)
Other
15
What do you use on your skin at home? Please list all brands and names of product.(ex: "Ultra Gentle Cleanser by Face Reality", "Stability Moisturizer by Live by Skin", "Armor SPF by Live by Skin")
16
Is there a chance you are pregnant?* This field is required.
YESNO
17
Live by Skin typically recommends an entire new regimen of professional-grade products to align with your professional treatments. Are you open to trying a new home-care routine?* This field is required.We want to be respectful of your boundaries.
YESNO
18
Are you breastfeeding, nursing, or pumping?* This field is required.
YESNO
19
Are you taking any contraceptives?* This field is required.Please select yes if you have another form of birth control implanted.
YESNO
20
Do you wear contact lenses?* This field is required.
YESNO
21
Are you on any special kind of diet? If yes, please explain below.* This field is required.If no, please type "n/a".
22
Have you undergone any surgeries in the past year?* This field is required.
YESNO
23
Dormant Acne & Purging* This field is required.Acne can take up to 90 days to form beneath the skin. If this is your first facial in a while, there is always the possibility of your skin detoxing from the professional exfoliants and facial manipulation administered in your treatment. We are unable to guarantee that you will or will not purge post treatment. Please initial to acknowledge this risk.
Initial Here
24
Pre and Post-Care Treatment* This field is required.Failure to follow recommended pre and post care limits our control over your results. Though for this treatment, we do not require you to use a "prescribed" homecare regimen from our esthetician, we do recommend you follow one to get the best possible results. Please initial below to acknowledge that you understand this statement, and the risks of not using a Live by Skin recommended homecare regimen. By initialing below, you understand that failure to use recommended homecare products can negatively affect the results of your treatment, and that we cannot guarantee any results-driven changes to your skin.
Initial Here
25
Do you verify that all of the provided information is accurate?* This field is required.New Health History Information I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform my skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
YESNO
26
Date this form is completed.* This field is required.Date this form is completed.
Date
Year
Month
Day
27
Signature* This field is required.This agreement will remain in effect for this procedure and all future procedures conducted by my technician. I have read the above information. If I have any concerns, I will address these with my esthetician. I do not hold the esthetician/technician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today. By signing below, I verify that I have disclosed all changes to my current health and history.
Should be Empty: