Facial Treatment - Client Intake Form

New Client Intake Form

Client is required to fill out form before appointment, the following questions must be answered thoroughly and in much detail as possible.
Name

First NameLast Name
Date of Birth

MonthDayYear
Ethnicity
Phone Number
Please enter a valid phone number.
Email
example@example.com
Your Health and Lifestyle

Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other physician’s care?*

YesNo
If yes, please specify:
Have you had any health problems in the past or present?*

YesNo
If yes, please specify:
Do you have any food or medicine allergies?*

YesNo
If yes, please specify:
Please indicate if you have used any of the medications or drugs listed below in the last 2 years.

Antibiotics (oral)Antibiotics (topical)AccutaneBenzoyl PeroxideRetin-A, Tazorac, DifferinThyroid medicationBlood Thinning Meds
If you selected yes to any above please specify when and how long
Please list any other medications or drugs that you have used in the past 2 years and specify when, and how long
Do you smoke?*

YesNo
Do you exercise regularly?*

YesNo
Do you follow a restricted diet?*

YesNo
Do you have metal implants, a pacemaker or body piercings?*

YesNo
Do you wear contact lenses?*

YesNo
Do you sunbathe or use tanning beds?*

YesNo
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?*

YesNo
Have you ever experienced claustrophobia?*

YesNo
Are you currently, or have you previously experienced any of the following (Check All That Apply):

Heart ConditionPacemakerAnemiaLow Blood PressureHigh Blood PressureCancerThyroid Conditionkidney ProblemsAsthmaDiabetesHepatitisHerpes SimplexAIDS/HIV PositiveAutoimmune DisorderLupusEczemaStaph Infection/MARSAHormone ProblemsMetal Pins in body
If you selected any options form above please elaborate
Rate your stress level on a scale of 1 to 5*

1

2

3

4

5

1 is Low, 5 is High
Occupation
Do you work nights

yesNo
Your Skin
What are your specific concerns / challenges with your skin?*
Please list bellow the skin care products you use AM and PM, including the brands.*
New clients are always recommended a full skincare regimen that is necessary to help you achieve your goals. One to two products will also be necessary before certain treatments. What is your budget for home care products? Please remember what we use on our skin everyday will make or break any results. (some clients put down the total of their current skincare routine)
Have you had chemical peels, microdermabrasion, botox, filler, laser treatments, skin cancer removal, or any other resurfacing treatments done in the last 90 days?*

YesNo
If yes, please specify what and when
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?*

YesNo
If yes, in the last month?
Are you currently using any products that contain the following ingredients?*

Glycolic acidLactic acidExfoliating scrubsHydroxy acid productsVitamin A derivatives (ie., Retinol)None
Have you ever experienced the following conditions on your skin?*

FlakinessTightnessObvious drynessNone
Have you gotten waxed in the past week

YesNo
What SPF sunscreen do you use on your face?
What SPF sunscreen do you use on your body?
Do you burn easily in moderate sunlight?*

YesNo
Do you suffer from sinus problems?*

YesNo
Do you ever experience burning, itching or stinging sensations on your skin?*

YesNo
Do you have a tendency to redness?*

YesNo
Female Clients Only
Are you taking oral contraception?*

YesNo
Are you pregnant?*

YesNo
Are you lactating?*

YesNo
Are you currently having or due for a menstrual cycle?*

YesNo
Male Clients Only
Do you have shaving challenges?

YesNo
If yes, please specify:
Clients must reschedule or cancel 24 hours before appointment to avoid being charged half the amount of the selected facial or treatment. Clients will be charged the full amount of the service for a no call-no show. If you are more than 15 min late to your appointment it will be cancelled and considered a no call no show. Thanks for understanding

We ask that you please reschedule or cancel at least 1 day before the beginning of your appointment or you will be charged a cancellation fee. Clients will also have progress photos taken and saved in their chart at the beginning and end of every treatment. Unless you check the box bellow they will never be posted.
I have read and agree to the Cancellation policy of the Complexion Esthetician. Please contact The Complexion Esthetician to learn more about their privacy practices.

Yes
By checking the first or second box below, you give Hayley Leonard permission to use your photographs and treatment notes in their publications, advertising and other forms of media. You understand these items will be reused, published, and republished individually or in connection with other material, in any and all media now or hereafter known, including the internet, printing and for any purpose whatsoever, specifically including, promotion, marketing, advertising and trade, without restriction as to alteration.*

Post the content and show my resultsShow my results but don't show my eyes or any identifying featuresI don't want my results shown
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. *

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If under 18...
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

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New Client Intake Form

Your Health and Lifestyle

Your Skin

Female Clients Only

Male Clients Only

If under 18...