Client Intake Form

Phenix Salon Suites

3813 South Nova Road, Unit 105

Suite 124

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.
Home or Cell Phone*

HomeCell
Email *
example@example.com
Do you give permission for us to contact you via email or text?*

EmailTextDo Not Contact
Age*
Date Of Birth*

MonthDayYear
Date
Ethnicity (To Determine Skin Types)*

American IndianAlaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderTwo or More RacesWhite
If Two or More Races, please describe.
I am concerned with the following:*

AcneAge SpotsSun DamageFine LinesRosaceaClogged PoresSkin ImperfectionsSkin TagsSebaceous HyperplasiaTelangiectasia (broken blood vessels)Cherry Angiomas (red dots)Facial HairOther
Medications

Please check all that apply
Choose All That Apply*

AntibioticsAccutane/IsotretioinBenzoyl PeroxideRetin-A or Tretinoin CreamRetin-A or Tretinoin GelTazoracDifferinAzelexAvitaCleocin-TE-Mycin-TCopaxoneCortosteroidsQuinineAndrostendioneTestosteroneProgesteroneThyroidGonadotrophinDanzolCyclosporinLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaCocaine/SpeedBlood ThinnersAnti-DepressantsNon of the aboveOther
Checked Meds, please describe when and how long you are or were on them
Medical History

Please check all conditions that apply
Conditions*

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins/Screws in BodyOther
Primary Care Physician
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Are you under a dermatologist's or other physician's care?

YesNo
If Yes, Doctor's Name(s)
Lifestyle Considerations
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
If Yes, what products
Please check any of these you are allergic to:

SulfurAspirinLatex
List any other allergies you know of:
Do you smoke or vape?*

YesNo
Do you use fabric softener or dryer sheets?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tars, oils, grease or inks?*

YesNo
Occupation?*
Do you work nights?*

YesNoSometimes
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)*

YesNo
WOMEN: Do you use birth control pill, shots or use and IUD?*

YesNo
If so, please describe which you use? What brand?
MEN: Do you have shaving irritation?*

YesNoI don't shave
What type of razor do you use for shaving?
Diet - Do you consume the following foods and/or supplements?
Check off foods you consume:*

Fast FoodProcessed FoodSalty SnacksMilk/YogurtCheeseWhey or Soy ProteinPeanut ButterPeanutsSushiKelp and SeaweedMiso SoupSoyVitaminsSeafood
If checked, please describe how often per week
Areas of Concern?*

FaceEyesLipsNeckChestBackOther
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?
Dermabrasion?
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. The treatments I receive are voluntary and I release Nancy Russ Aesthetics or Nancy Russ licensed skin care professional from liability.

Treatments may include but are not limited to facials, extractions, hydro facial, enzyme exfoliation, chemical exfoliation, microdermabrasion, dermaplaning, microchanneling, facial waxing, brow or lash tinting.
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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