Skin-care Intake Form

Name

First NameLast Name

Date

Date of Birth

Date

Phone (day)

Format: (000) 000-0000.

Address

Street Address Line 2

City/State/Zip

Occupation

Email

example@example.com

Primary Physician

Phone

Format: (000) 000-0000.

Emergency Contact

Relationship

Phone

Format: (000) 000-0000.

How did you hear about us?

Mark any that apply

What type of skin do you have?

What areas of concern do you have regarding your skin?

If yes, please explain

Have you been under the care of a dermatologist within the past year?

If yes, please explain

Have you ever had an allergic reaction to any of the following

Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? If yes, please describe:

Have you received Botox, Restylane, or Collagen injections in the last 6 months?

If yes, please specify

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I agree to inform the therapist of any experience of pain during the session. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I understand this does not defer me from seeking medical treatment for medical conditions. I understand that no inappropriate comments or conduct will be tolerated. Any indication of such behavior will automatically

I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history. I agree to hold harmless the establishment, all management, including volunteers, from and against any and all claims.

Our time together is valuable and I agree to cancel, if need be, 24 hours in advance of my appointment session. If I miss an appointment or fail to cancel within the 24 hour period, I agree to pay 50% of the full amount. If necessary, I may be required to prepay with a valid form of payment to secure my appointment.

By signing below, you agree to the following.

I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time.

Name

First NameLast Name

Client Signature

Date

Skin-care Intake Form

Skin care information