NEW Client Intake Form
General Information
Date
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Date
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
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District of Columbia
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New York
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
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Month
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Day
Year
Date
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
If referred from a client please list their name so we can thank them!
The most valuable thing you can give someone is your time, and we fully believe that everyone’s time should be respected. We understand sometimes it is necessary to reschedule or cancel an appointment; however, we ask that 24 hours notice is given prior to cancelling. In the event that you are unable to give us a 24 hours notice, a cancellation or “No Show” fee of $50 will be charged to your card. If you arrive more than 10 minutes late to your scheduled appointment, we have the right to ask you to reschedule. We apologize for any inconvenience this may cause.
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Skin History
Concerns (check all that apply)
Acne/Acne Scarring
Brown Spots/Sun Damage
Crows Feet
Deep Lines/Shadows
Dry Skin
Fine lines/wrinkles
Flushing of the skin
Large Pores
Melasma
Oily Skin
Pigmented Lesions
Rosacea
Skin Laxity
Skin Texture/Scars
Unwanted Hair
How long have you had any of the above concerns?
Are you currently being treated for any of the above conditions?
Yes
No
Are you currently taking any medications for a skin condition?
Yes
No
Have you or any one in your family had skin cancer?
Yes
No
Have you had a reaction to lotions, creams, or oils?
Yes
No
If you answered yes to any of the last four questions, please explain:
Personal History
Do you smoke?
Yes
No
Do you drink alochol?
Yes
No
Do you exercise regularly?
Yes
No
Do you wear contact lenses?
Yes
No
Do you have any metal implants?
Yes
No
Cosmetic History
Have you ever had Botox and/or Dermal Filler treatments?
Yes
No
Have you had a reaction to ANY cosmetic procedure? (i.e. Botox, Fillers, Lasers, Chemical Peel)
If yes, please explain:
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Medical History
Please check ALL that apply to you:
Active Infection
Alcoholism
Anemia
Anorexia
Arthritis
Asthma
Autoimmune Disease
Bleeding Disorders
Breast Lump
Bruising
Cancer
Chemical Dependency
Chest Pain
Chronic Fatigue
Connective Tissue Disorder
Diabetes
Eating Disorders
Epilepsy or seizures
Fibromyalgia
Heart Disease
Hepatitis A, B or C
Herpes
High Blood Pressure
Hormone Imbalance
HIV/AIDS
Keloid Scarring
Mirgraines
Multiple Sclerosis
Neurologic Disorder
Neuromuscular Disorder
Pacemaker/Defibrillator
Pigmentation Disorder
Polycystic Ovaries (PCOS)
Sensitive Teeth
Skin Cancer/Moles
Skin Injury/Lesions
Thyroid Disorders
Vision Deficits
Are you taking any blood thinners?
Yes
No
Do you take Aspirin or Ibuprofen?
Yes
No
Are you taking any supplements? If yes, please list here:
(Vitamin E, Fish Oil, etc.?)
Please list ANY medications you are taking:
Please list ANY allergies or type NONE:
*
Do you have any muscle issues? (i.e. Bell's Palsy, Nerve Injuries?)
If yes, please explain
Females: Are you pregnant or planning to become pregnant?
Yes
No
Females: Are you nursing?
Yes
No
Is there any other information you would like your technician or our staff to be aware of?
May we use your before and after photos WITHOUT identifying you in advertising?
Yes
No
I have answered the questions contained in this questionnaire to the best of my knowledge. I understand it is my responsibility to inform my technician of my current health conditions while seeking treatment as a patient. I will update this information as it occurs if there are changes to my health between treatments.
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