Service and Health Intake Form

Today’s Date*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation

Birthdate*

Date

Where were you born?

Where were you raised?

Email*

example@example.com

May I contact you via mail/e-mail about future promotions and news?

YesNo

Phone Number

Area CodePhone Number

Phone Number- Cell

Area CodePhone Number

May I text you at the provided cell number to confirm future appointments?

YesNo

Occupation:

What is your nationality( not ethnicity)? (only used for skin typing purposes.)

How did you hear about Perfectly Polished?*

If you were referred by a current client, please include their name.

List any medications, supplements, or herbal remedies you currently take: including hormone replacement.*

Do you take oral contraceptives?

yesno

Please list allergies or sensitivities:*

Please list Injuries or surgeries:*

Do you or have you experience any of the following? Check all that apply

Do you have any special skin problems or concerns pertaining to your face and/or body?*

What have you tried in order to alleviate your concerns?

How would you describe your overall health right now?

Any current health issues?

What is your stress level right now?*

LowAverageSomewhat StressedVery Stressed

Do you smoke, vape, or consume other tobacco products? If yes, type, for how long and how much per day? If you have quit, how long ago?

Do you sleep well?

Do you exercise regularly?

Do you follow a low-carb or fat free diet?

Do you restrict sugar in your diet?

How many glasses of water do you consume daily?

Do you drink caffeine?

Do you drink alcohol?

Are you a vegetarian?

Are you a Vegan?

Have you ever had any of the following? If so, when and where on the body?

Fever Blisters/Cold Sores/Herpes?

Acne?

Claustrophobia? If yes, would a mask disturb you?

Diabetes? If yes, what type?

noType 1Type 2

Eczema?

Epilepsy? If yes, describe the warning signs.

Joint Replacement?

Heart Disease? If yes, what type?

Pacemaker or Valve Replacement?

Metal Implants?

Hepatitis?

Menopause or Peri-Menopause?

Please check all that apply.*

What do you consider your skin type?*

Do you ever experience the following with your skin?? Please check all that apply.

FlakinessTightnessRednessOily shine

Do you blush easily?

Do any of the following trigger a blush? Please check all that apply.

EmotionFoods, especially spicy foodsTemperature ChangesOther

What areas of concern do you have regarding your SKIN...check all that apply

EYES...check all that apply

LIPS...check all that apply

DehydratedCracked/ChappedOther

Does your skin:

Do you or have you sun bathed or used tanning beds? If so please include when.

Did you spend a lot of time outside or swimming when you were a child?

Have you used any hair removal methods in the past 6 weeks?

If you have had skin cancer, please list what kind, where, if it was removed and what treatment if any.

What is your present skincare regimen??

Cleanser

Toner

Moisturiser

Mask

Exfoliation

Sunblock...include SPF

Other

Please check all that you have used:

Any family history of skin cancer? If so, please list.

Have you ever had a reaction to any of the following? Please check all that apply.

Have you ever had any of the following? Please check all that apply.

If you checked any of the above, please include when and any reactions.

Please check any that you are using or have used in the past 7 days.

HydroquinoneRetin A/ Retinoic Acid/ TretinoinAlpha Hydroxy AcidsSalicylic Acid

What is your goal for this session.

By submitting this form, I agree to the following:

I give my permission to receive skincare, waxing, nail and/or pedicure services.

I understand Bethany does not diagnose illnesses and/or injuries and does not prescribe medications.

I understand that any homecare suggestions are given based on the health of my skin and should be used according to the instructions given to me.

If I am a current cancer patient, I have been given written clearance from my doctor to receive services in accrdance to Bethanys Oncology Aesthetics protocols.

I have been told and understand the risks associated with receiving skincare, waxing, nails and pedicure services.

I understand the importance of truthfully answering all the above questions and of informing Bethany about any changes in my health and/or medications. If I do not, I understand there may be risks in my treatment and outcome.

I understand that it is my responsibility to inform Bethany of any discomfort I may be experiencing during my services so that she may adjust accordingly.

I have been given the chance to ask any questions I may have about the services I will receive.

Having answered all questions truthfully and to the best of my ability, I therefore release Bethany Boyd and Perfectly Polished LLC of any liability concerning services and/or outcomes that may occur.

Signature*