General Intake Form

Name

First NameLast Name

Birthday

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Esthetics Information

Are you currently under the care of a dermatologist?

Please list all known allergies (including but not limited to aspirin, sugarcane, milk, shellfish, latex, etc.) if none type N/A

Do you currently or have you used in the last 3 months any Retin-A, Renova, Tretinoin, AHAs, or a vitamin A derivative?

Have you received any Botox or fillers in the last 2 weeks?

Are you currently pregnant or planing to become pregnant?

Are you currently breastfeeding?

Please list all current medications

By signing below, you agree to the following:

I have completed this form to the best of my ability and acknowledge and agree to information given above. I have agreed to disclose any changes needed in the future. I have been informed of and agree to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment a contraindication. I will inform the esthetician of any discomfort I may have at any time during the service. I agree to waive any and all liabilities towards Bareskin Beauty LLC for any injury or damages incurred due to any misinformation of my health history. I assume all risks associated with my services

Signature

Is this treatment for a minor?

By signing this form, I understand and agree to the information provided above, and in addtion: I verify that the minor is of succifient age and aptitude as to provide verbal feedback to the esthetician before, during and after treatment. I also understand that I am welcome and encouraged to remain in the treatment room or area during the entire length of treatment.

Signature

Date

Name of Minor

First NameLast Name

Signature of Minor

Date

Parental/Guardian

Date

Bareskin Beauty

Photo Consent