Acne Clearing Journey Client Intake Form

Acne Clearing Journey Client Intake Form
Client's Name*

First NameLast Name
Preferred Name
Preferred Pronouns
Date of Birth*

MonthDayYear
Date
Ethnicity*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email Address*
example@example.com
How did you hear about us?*
Share your Instagram handle if you would like to be added to our Clients-Only Close Friends group!
Please indicate which medications you’re currently using and have used in the past, as well as when and how long.*
Please check all that all apply:

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins in BodyHypertensionHypotensionDefibrillatorHeart DiseaseEpilepsy or SeizuresBlush EasilyHepatitis A/B/CMigraines/HeadachesDepression/AnxietyRosaceaBruise EasilySpinal Cord InjuryKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Your Primary Care Physician:
Name
Primary Care Physician contact:
Phone number
Are you under a dermatologist’s or other physician's care?*

YesNo
If yes, doctor’s name:
Name
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:*

SulfurAspirinLatexNo allergies to the above
List any other allergies you know of. Type N/A if not applicable:*
Do you smoke?*

YesNo
Do you use fabric softener or fabric softener sheets in the dryer?*

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?*

YesNo
How many hours of sleep are you getting on average daily?*

Less than 5 hours6-7 hours7-8 hours8+ hours
How much is your water intake on average daily?*

Less than 20 oz a day20-40 oz a day40-60 oz a day60+ oz a day
Are you currently under a lot of stress? (Common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)*

YesNo
Do you use birth control pills, shots, or use an IUD?*

YesNoN/A
If yes, which do you use? If not, indicate N/A*
Indicate birth control pills, shots, or IUD
What brand of pill? Or indicate N/A*
Are you pregnant or nursing?*

YesNo
Do you:*

Wear contact lensesHave a pace makerHave metal implantsHave facial piercingsNone of the above
Do you have shaving irritation on the face?*

YesNo
What type of razor do you use for shaving?
Do you consume alcohol?*

YesNo
Do you consume caffeinated drinks?*

YesNo
Are you currently under any kind of diet?*

YesNo
If so, please indicate which one. Check all that apply:

KetoPaleoGluten-FreeDairy-FreeOther
Any known allergies to:*

AspirinTree NutsLatexDairyIodineFragrance/Essential OilsOtherNone
Diet - Do you consume the following?*
Products Currently Using - Please include Brand Names*:
Please include a photo of all the products/topicals you're using on a daily basis. Thank you!*

Cancelof
Other Treatments: What else have you done for your skin in the last 90 days?*
What are your day + time preferences for scheduling? Latest PM appointment on M, W, TH is 3:30pm; on Fridays - 4:30pm // You can choose as many options!*

Monday AMMonday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PM
Do you release consent for your photos to be taken for client progress history?*

YesYes, with eyes coveredOther
Do you release consent for your photos to be used for social media/marketing purposes?*

YesYes, with eyes coveredNo
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

I understand that my facial treatment may include clincal-strength products, enzymes, acid peels, and other treatment modalities (i.e. steam, extractions, nano infusion, LED light therapy, and high frequency) as necessary or requested.

I understand that there may be some degree of discomfort, i.e. stinging, prickling sensations, hotness, or tightness.

I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact my Service Provider.

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection from a minimum SPF 30 is mandatory.

I will reveal any medical condition that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or use of Retin-A. Contraindicated medications should be discontinued five days prior to the treatment, with exception of Accutane, which must be discontinued for six months prior.

I have not had a peel treatment of any kind within 14 days of my treatment from my Service Provider or any other Service Providers. I understand I cannot have another treatment until recommended by my Service Provider. I understand my responsibility of properly fulfilling the appropriate after care instructions as explained by my Service Provider.

PHOTOGRAPHS: I give permission for photographs to be used by my Service Provider for monitoring my treatment progress.

Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform my Service Provider of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

I have read the contents of this consent form carefully, and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions been answered to my satisfaction.

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

With my signature below, I give consent to receive treatments from Skin Revival Studio and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that Skin Revival Studio neither diagnoses illness, disease, or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. Because the Service Provider must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations, and I will inform the specialist in writing of any change in my physical health. I agree that this constitutes full disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider for any services rendered.
Client Signature*

Clear
I understand and agree to comply with all of Skin Revival Studio's policies:

1. I will not treat clients with questionable medial conditions such as Herpes Simplex (active cold sores and fever blisters), open wounds or sores, healing incisions, infectious diseases, etc. I do not manage clients undergoing cancer, diabetes, or systemic treatments of any specific contraindications for the body.

2. I require a minimum of 48 hours advance cancellation notice. Any client giving less will be charged 50% of the service fee. Any clients who No Calls + No Shows their appointment will be charged 100% of the fee. Any clients who arrive 15 minutes after their appointment time will be charged 100% of the appointment fee.

3. If an appointment is rescheduled for the second time, a nontransferable, nonrefundable deposit of 50% of the service fee will be made via electronic invoice before the second rescheduled appointment request is accepted.

4. I understand that services received here are NOT a substitute for MEDICAL CARE and any information provided by the technician is for educational purposes only.

5. All information received by the client on this chart is completely private and confidential.

6. By signing this form, I consent to being added to email marketing.

7. ALL SALES ARE FINAL.
Client Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Acne Clearing Journey Client Intake Form

Terms & Conditions