New Client Intake Form

602 W Indian River Blvd

Suite 3

Edgewater, FL 32132

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.
Home or Cell Phone
Email
example@example.com
Do you give permission for us to contact you via email or text?
Age
Date Of Birth

MonthDayYear
Date
Ethnicity (To Determine Skin Types)
If Two or More Races, please describe.
I am concerned with the following:

Other
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.
Choose All That Apply
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.
Conditions

Other
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.
Are you under a dermatologist's or other physician's care?
If Yes, Doctor's Name(s)
Areas of Concern?

Other
Lifestyle Considerations
Have you ever had any reaction to any products or anything you have put on your face?
If Yes, what products
Please check any of these you are allergic to:
List any other allergies you know of or enter NA:
Do you smoke or vape?
Do you use fabric softener or dryer sheets?
Do you swim in a chlorinated pool?
Do you work around chemicals, tars, oils, grease or inks?
Occupation?
Do you work nights?
Are you currently under a lot of stress? (common stress = job loss, new job, wedding, divorce, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)
If Yes, Please expain
WOMEN: Do you use birth control pill, shots or use and IUD?
If so, please describe which you use? What brand?
MEN: Do you have shaving irritation?
What type of razor do you use for shaving?
Products Currently Using

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

Which treatments have you had?
Chemical Peels?
What kind, when and where?
Dermaplane?
When and where?
Microdermabrasion?
When and where?
Microneedling
When and where?
Laser Hair Removal?
When and where?
Laser Rejuvenation/Resurfacing?
What kind, when and where?
Skin Cancer Removal?
What kind, when and where?
Facial Waxing?
When and where?
Electrolysis?
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, Microneedling, Nano-Infusion, Ultrasonic, Galvanic Current, Dermaplane, Facial Waxing, Brow or Lash Tinting. Additional Consents will be required per modality.
Signature
Date

MonthDayYear
Date
Should be Empty:

CLIENT INTAKE FORM

Medications

Medical History

Primary Care Physician

Lifestyle Considerations

Products Currently Using

The Last 90 Days