Client Intake and Med HX

Client Intake Form & Medical History
In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. Please answer honestly, all information is confidential.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How did you hear about JJ's Beauty Bar?
Are you currently under the care of a physician for any reason?*

YesNo
If yes, for what?
Please select all that apply to you*

AsthmaCardiac ProblemsChronic HeadachesDepressionHerpesFever BlistersAnxietyEpilepsyHysterectomySkin DiseaseHepatitisHigh Blood PressureSinus ProblemsImmune DisordersLupusPacemakerEczemaMetal implants, ie; bones, pins, platesDiabetesNone
Please explain above problems or list any other significant issues
Are you currently taking any medications?*
If so, please list them
Are you pregnant?*

YesNo
Are you currently taking birth control?*

YesNo
If you are taking birth control, what type?
Are you presently using, or have used in the last 6 months, any of the following?*

AzlexDifferinRenovaRetin-A, TretinoinTazaracGlycolic or Alpha Hydroxy AcidsAccutaneMetrogel, MetroCreamRadiation (Last 3 Months)None Of The Above
If "yes", when and for how long?
Please list any allergies you have*
Please list your current skincare routine and what products you use*
What are your main concerns with your skin?*
I understand that the services offered by JJ's Beauty Bar are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving appropriate services and is completely confidential. I have signed the consent form for this procedure. I had the opportunity to ask questions prior to the treatment.
Client Signature*

Clear
Consent to treatment of a minor
By signature below, I hereby authorize esthetician name to perform esthetic services to my child or dependent, as they deem necessary.
Signature
Should be Empty:

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Client Intake Form & Medical History