NEW Client Intake Form
*Required to be submitted Prior to first appointment*
Full 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.
Birthdate
*
-
Month
-
Day
Year
Date
Gender
Female
Male
I identify as:
Email
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
How did you hear about us?
*
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Health History
Have you currently or previously ever experienced the following, check all that apply:
*
Heart Condition
Headaches
Anemia
High Blood Pressure
Low Blood Pressure
Cancer
Thyroid Condition
Kidney Problems
Epilepsy
Arthritis
Hemophilia
Asthma
Diabetes
Hypo/Hyper Glycemia
Hepatitis
Herpes Simplex/ Cold Sores
PCOS
Endometriosis
AIDS/HIV Positive
Metal Stents
Bell's Palsy
Implanted electrical devices
Hormonal Imbalance
None of the above
Other
Please list any allergies including any adverse reactions from skincare products or treatments.
*
Please list any prescribed medication, OTC medication, or supplements you are currently taking (please include any oral contraceptives or any forms of birth control).
*
Are you currently pregnant, breastfeeding, or trying to become pregnant?
*
Pregnant
Breastfeeding
None of the above
Other
Do you smoke?
*
Yes
No
Other
Do you suffer from claustrophobia or anxiety?
*
Yes
No
Other
Have you had any Botox, filler, or any facial procedure in the last two weeks?
*
Yes
No
Please specify which facial procedure:
Have you had any direct sunlight or sun exposure within the last two week?
*
Yes
No
Have you used any hair removal methods on the face in the last 2-4 week?
*
Yes
No
If yes, please specify:
Have you used an derivative of Vitamin A (Accutane, Retin-a, Renova, Adapalene, Retinol, etc)?
*
Yes
No
If yes, please specify:
Have you ever been on Accutane?
*
Yes
No
If yes, please specify last dose and duration of use:
Which of the following best describes your skin type? (Please check one)
*
Type I Fair skin tones—Always burns, never tans
Type II Light skin tones—Burns easily, tans slightly
Type III Fair to olive skin tones—Burns moderately, tans moderately
Type IV Light brown skin tones—Burns slightly, tans easily
Type V Dark brown skin tones—Rarely burns, tans easily
Type VI Dark brown to black skin tones—Never burns, tans easily
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Skin Health
I am visiting Sophia Hermida Aesthetics for:
*
Corrective Treatments
Homecare Routines
Relaxation
Other
What are some areas of concern with your skin that you would like to improve?
*
Overall Tone and Color
Texture
Premature Aging
Wrinkles
Firmness
Décolleté
Neck Area
Eye Area
Smoothness
Blackheads
Breakouts
Acne
Scarring
Pore Appearance/Size
Dryness
Oiliness
Other
Please feel free to express your concerns and goals in detail:
What is your current skincare routine? (Please list in-detail products & brands)
*
Please insert an image of all your skincare products you use at home:
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Before + After photos will be taken to ensure your skin's progress, only providers will have access to these photos. Do you consent to “before + after” photographs for the purpose of documentation, potential advertising, and promotional purposes.
*
Yes, I do consent to use photographs for the purpose of documentation, potential advertising, and promotional purposes.
No, I do not consent to use photographs for the purpose of documentation, potential advertising, and promotional purposes.
Yes, I consent to before + after photos to keep in the hands of providers only.
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Client Intake Form Agreement
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skincare professional from liability and assume full responsibility thereof.
*
Yes, I understand.
Full Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: