New Client Intake Form:
Thanks for booking with Y + Y Beauty in Thousand Oaks! Please fill out all forms at least 24 hours prior to your appointment. Be advised that your appointment may be rescheduled or canceled if any contraindications apply. I look forward to meeting you!
Full Name
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First Name
Last Name
Phone Number
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Format: (000) 000-0000.
E-mail
example@example.com
Birthday
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Month
-
Day
Year
Date
How would you describe your skin type? Check all that apply.
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Dry
Oily
Combo
Normal
What are your skin concerns? Check all that apply
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I experience a lot of breakouts
I get pimples here and there
My nose looks like it has a ton of black heads
I would like to plump up my fine lines and wrinkles
I want to remove my peach fuzz
I wish my skin was brighter/even-tone
I have a lot of sun damage
My skin feels greasy all the time
I have scarring leftover from acne
Everything I use irritates my skin
My skin never has a glow
My skin feels congested
I wish my skin felt smoother
My skin turns red easily
What is your current relationship with skincare?
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I love trying different products all the time
I have a routine that works for me
I don’t feel like my products are working for me
I don’t know much about skincare
Have you been under the care of a dermatologist within the past year. If so, what for?
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Do you currently use Accutane, Retin-A, or any other prescription skincare products? Please specify.
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Have you received any injectables such as Botox, Juvederm, Dysport, Restylane, etc.? If so, please specify treatment and how long ago.
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Do you have any skin diseases/disorders that have been diagnosed by a doctor? Please specify.
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Have you received chemical peels, microdermabrasion, dermaplaning, or any other resurfacing treatments? Please specify treatment and how long ago.
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Do you have metal implants, pacemaker or piercings? Please specify.
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Do you have any allergies or sensitivities? Please specify.
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Are you pregnant, lactating or trying to become pregnant? Please specify.
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List any medications you take regularly.
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List any skin treatments, waxing, etc. that you receive regularly.
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List any dietary restrictions.
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Do you smoke/drink alcoholic beverages /consume caffeine regularly? Please specify.
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Do you play sports or workout regularly?
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Yes
No
Do you wear makeup regularly?
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Yes
No
Do you tan regularly indoors or outdoors?
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Indoor
Outdoor
No
Do you wear sunscreen regularly? (Not included in makeup)
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Yes
No
How often are you using your skincare products?
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Morning only
Night only
Morning and night
Neither
Are you claustrophobic?
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Yes
No
List all skincare products and brands you are currently using. (Cleansers, Exfoliants, Toners, Serums, Moisturizers, Oils, Masks, SPF, Tools, Etc.) Please be specific.
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My favorite part of a facial is:
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Are there any treatments you’d like more info on?
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Dermaplaning
Deep cleanse Treatment
Ultimate Anti-aging Treatment
Collagen Rejuvenation Treatment
Other
How did you hear about Y + Y Beauty?
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Referral
Instagram
Google
Facebook
Other
I give Yanell Delgadilli and Y + Y Beauty permission to take photo and/or video of me during my service to use for promotional and educational purposes, as well as to keep track of my progress between treatments.
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I agree.
If I experience any pain or discomfort during the session I will immediately inform Yanell Delgadillo so that the session may be adjusted to my level of comfort. I further understand that aesthetic treatments should not be considered a substitute for medical examination, diagnosis, or treatment, and that I should see a physician or other qualified medical specialist for any mental or physical alignment that I am aware of. I understand that licensed estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness, and nothing in the course of the session should be constructed as such. Because certain aesthetic treatments should not be performed under certain medical conditions, I affirm that I have stated all my non-medical conditions and answered all questions honestly. I agree to keep Y + Y Beauty and Yanell Delgadillo updated as to any changes in medical profile, and I understand that there shall be no liability on Y + Y Beauty or Yanell Delgadillo as I should fail to do so.
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I agree.
Will you be willing to recommend us?
Yes
Maybe
No
Signature
Date
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Month
-
Day
Year
Date
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