Form
Client Intake Form
Patient Profile
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Sex:
Male
Female
Other
Age:
Hereditary Background:
Nordic
Scandinavian
Irish
English
Asian
Mediterranean
Hispanic
Native American
Middle Estern
African American
Other
Natural Eye Color
Natural Hair Color
Do you consider your skin (fill in best option):
Sensitive
Resilient
Unsure
Describe your skin (fill in all that apply)
Normal
Dry
T-zone
Combination
Thick
Thin
Saggy
Firm
Oily
Acne
Comedones
Blackheads
Mila
Cysts
Breakouts
Acne scared
Large pores
Small pores
Rosacea
Eczema
Freckled
Wrinkled
Patchy dryness
Pcoriasis
Dehydrated
Lacking moisture
Asphyxiated
Telangiectasia/ Broken surface capillaries
What are the changes you'd most like to see in your skin?
Are you pregnant or lactating?
No
Yes
Do you wear contact lenses?
No
Yes
Do you currently have a sunburned/windburned/red face?
No
Yes
Are you in the habit of going to tanning booths? (if within passed 1 4 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.)
No
Yes
Do you participate in vigorous aerobic activity or sports?
No
Yes
Do you smoke or use tobacco?
No
Yes
What kind of work do you do?
On average, how many hours per week do you spend outdoors?
Do you currently use depilatories or wax? (Discontinue use for 5 days pre-and post-treatment.)
No
Yes
Have you had a chemical peel or any type of procedure with a medical device? Within the last 14 days?
No
Yes
Do you have regular collagen, Botox or other dermal filler injections? (Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.)
No
Yes
Have you recently had laser resurfacing or facial surgery?
No
Yes
Are you currently taking any medications topical or otherwise? (High percentages of certain ingredients may increase sensitivity. Discontinue use for 5 days before and after treatment. Consult your physician before discontinuing use of any prescription.)
Tretinon
Retin-A
Renova
Differin
Tazorac
Avage
EpiDuo
Ziana
None
Have undergone Accutane therapy? (If you are currently using Accutane therapy, please consult with your dispensing physician.
No
Yes
Do you develop cold sores/ fever blisters?
No
Yes
Are allergic/ sensitive to (fill all that apply) milk/apples/citrus/grapes/aloe vera/aspirin/ perfumes/latex/hydroquinone/mushrooms?
No
Yes
Have you ever used any other products that caused a bad reaction?
No
Yes
Patient Signature
Date
-
Month
-
Day
Year
Date
Submit
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