Client Intake Form

1728 Dunlawton Avenue, Unit 2

Port Orange, FL 32127

386-689-9161
CLIENT INTAKE FORM
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
HomeCell
Email *
example@example.com
EmailTextDo Not Contact
Age*
Date Of Birth*

MonthDayYear
Date
American IndianAlaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderTwo or More RacesWhite
If Two or More Races, please describe.*
AcneAge SpotsSun DamageFine LinesRosaceaClogged PoresSkin ImperfectionsFacial HairNone of the aboveOther
If Other, Please explain, if not, enter NA*
Medications

Please check all that apply. The reason we ask is to treat your skin holistically from the inside out and for possible contraindications for each modality.
AntibioticsAccutane/IsotretioinBenzoyl PeroxideRetin-A or Tretinoin CreamRetin-A or Tretinoin GelTazoracDifferinAzelexAvitaCleocin-TE-Mycin-TCopaxoneCortosteroidsHydroquinoneAndrostendioneTestosteroneProgesteroneThyroidGonadotrophinDanzolCyclosporinLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaCocaine/SpeedBlood ThinnersAnti-DepressantsNone of the above
Checked Meds, please describe when and how long you are or were on them
Medical History

Please check all that apply. The reason we ask is to treat your skin holistically from the inside out and for possible contraindications for each modality.
Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins/Screws in BodyOther
If Other, Please explain or enter NA
Primary Care Physician
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
If Yes, Doctor's Name(s)
Take Photo - Face Front
Take Photo - Face Left
Take Photo - Face Right
FaceEyesLipsNeckChestBackOther
Lifestyle Considerations
YesNo
If Yes, what products
SulfurAspirinLatexSulfa
List any other allergies you know of or enter NA:*
YesNo
YesNo
YesNo
YesNo
Occupation?*
YesNoSometimes
YesNo
If Yes, Please expain
YesNo
If so, please describe which you use? What brand?
YesNoI don't shave
What type of razor do you use for shaving?
Diet - Do you consume the following foods and/or supplements?

The reason we ask is to treat your skin holistically from the inside out.
Fast FoodProcessed FoodSalty SnacksMilk/YogurtCheeseWhey or Soy ProteinPeanut ButterPeanutsSushiKelp and SeaweedMiso SoupSoyVitaminsSeafood
If checked, please describe how often per week
If Other, Please describe:
Products Currently Using

Please provide names of products in detail and pictures would be great!
Cleanser
Take Photo
Exfoliants (acids, serums, scrubs)
Take Photo
Acne Medications
Take Photo
Toner
Take Photo
Serums
Take Photo
Eye Cream or Serum
Take Photo
Moisturizer
Take Photo
Sunscreens
Take Photo
Mask
Take Photo
Foundation
Take Photo
Blush
Take Photo
Concealer
Take Photo
Shampoo?
Take Photo
Conditioner?
Take Photo
Styling Products?
Take Photo
Anything else?
Take Photo
The Last 90 Days

Other Treatments: What else have you done for your skin?
Chemical Peels?
What kind, when and where?
Microdermabrasion?
What kind, when and where?
Microneedling
What kind, when and where?
Laser Hair Removal?
What kind, when and where?
Laser Rejuvenation/Resurfacing?
What kind, when and where?
Skin Cancer Removal?
What kind, when and where?
Facial Waxing?
What kind, when and where?
Electrolysis?
What kind, when and where?
How did you learn about my services?*
Referral, Google, Yelp,...
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritations to the skin from treatment received or recommendations given. The treatments I may receive are voluntary and I release Holistic Skin Center, Nancy Russ LLC, Nancy Russ from liability.

Treatments may include but are not limited to Home Care Products, Facial and Back Treatments, Enyzme Exfoliation, Chemical Peels, Extractions, Microcurrent, LED Light Therapy, Nano-Infusion, Ultrasonic, Galvanic Current, Dermaplane, Facial Waxing, Brow or Lash Tinting. Additional Consents will be required per modality.
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CLIENT INTAKE FORM

Medications

Medical History

Primary Care Physician

Lifestyle Considerations

Diet - Do you consume the following foods and/or supplements?

Products Currently Using

The Last 90 Days