Facials Intake Form

Forever Young Skincare

Client Intake Form for facials
By completing this client profile, you will assist us in evaluating your skin condition. The information you provide will be used to determine what factors may be affecting your skin so that we may recommend the proper care.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Age*
How did you hear about me?
Please list two emergency contacts*
Name and phone number
Health/Medical

Please answer to the best of your knowledge
Please check any health conditions which you have had or are now experiencing

CancerThrombosisRecent IllnessMultiple SclerosisHypoglycemiaDiabetesPregnancyPhlebitisLight/Photo SensitivityMetal Implants/ScrewsAsthmaLack of Normal Skin SensationEpilepsyHemophiliaHeart ProblemsHormonal DisordersThyroid DisordersRecent SurgerySeizuresHIVPacemakerClaustrophobiaMuscular ConditionsWhiplashLupusHepatitisAlcoholismSmokingHigh/Low Blood PressureSeizures
Please list your allergies*
If none, please enter N/A
Is there anything else you would like me to be aware of?
Have you ever undergone treatment from a Dermatologist?*

YesNo
When did you undergo treatment?*
What type of condition?*
What was the outcome and were there any side effects?*
Have you ever undergone treatment from an Aesthetician?*

YesNo
When did you undergo treatment?*
What type of condition?*
What was the outcome and were there any side effects?*
Within the last month, have you taken or used any of the following?

Retin AAccutaneAntibioticsOral ContraceptivesDiureticsLaxatives
Have you ever undergone plastic surgery?*

YesNo
When did you undergo surgery?*
When was the surgery?*
Where on your body was the surgery?*
What information can you provide about the procedure?*
Nutrition/Diet
Check any of the following foods that you consume and indicate the amount per day:
Sugar*

YesNo
How much?
Salty Foods*

YesNo
How much?
Spicy Foods*

YesNo
How much?
Snack Foods*

YesNo
How much?
Dairy Products*

YesNo
How much?
Meat Products*

YesNo
How much?
Check the types of fluids that you consume daily and indicate the amount per day:
Water*

YesNo
How much?
Coffee*

YesNo
How much?
Juices*

YesNo
How much?
Alcohol*

YesNo
How much?
Tea*

YesNo
How much?
Sodas*

YesNo
How much?
Home Skincare Regimen

Describe (using product brand names) how you are presently caring for your skin:

	AM	PM
Cleanser
Toner
Moisturizer
Make-up

	AM	PM
Exfoliant
Serum
SPF Sunscreen
Other

How many hours a night do you sleep?*
How often do you exercise?*
On a Scale from 1(low) to 10 (high) how would rate your stress level?*
How much sun exposure have you had?*
What are your goals and expectations?
What is your specific concerns about your skin?
How long have you noticed your condition?
Is this an ongoing or temporary condition?
What specific improvements do you want to see?
In what time frame do you expect to reach your goals?
Have you ever received a salon/spa skin care treatment?
What were the results?
Previous aesthetic treatments-check all that apply

	Yes/No	Date
Botox

	Yes/No	Date
Facial

	Yes/No	Date
Dermal Fillers

	Yes/No	Date
IP/Photo rejuvenation

	Yes/No	Date
Laser Treatments

	Yes/No	Date
Microdermabrasion

	Yes/No	Date
Oxygen Infusion Treatment

	Yes/No	Date
LED Light Therapy

	Yes/No	Date
Chemical Peels

	Yes/No	Date
Facial Waxing

	Yes/No	Date
Microcurrent

	Yes/No	Date
Other

Client Release
Caution: Do not perform microcurrent or vacuum message if any of the following conditions exist any severe health conditions or any of the following contraindications: Cancer, Epilepsy, History of Seizures, Pacemaker, Pregnancy, Thrombosis or Phiebitis, or if the conditions are unknown to you, consult a physician.

Caution: Do not perform microdermabrasion applications if any of the following conditions exist: Any severe health conditions or any of the following contraindications: any contagious disease, any drug causing sun sensitivity (Tetracycline), any drug or application causing thinning of the skin (Ratin-A or Accutane), blood transmitted diseases (HIV, Hepatitis, Herpes), Hemophilia, or if the conditions are unknown to you, consult a physician.

Caution: Do not perform light rejuvenation applications if any of the following conditions exist: Any severe health conditions or any of the following contraindications: Hypersensitivity to light or "photoallergy," tendency toward photo-toxic reactions, taking of photo-sensitizing or photo- Toxic medication, Cancer, Epilepsy, History of seizures, Lupus, Pregnancy, or if the conditions are unknown to you, consult a physician.
I certify that the above statements are true and correct and that I, Name* having been advised and fully informed by Christine Blaylock of Forever Young Skincare concerning the nature of the process proposed, to be performed by her, hereby authorize and direct her to perform such process and perform such services as may be deemed necessary or advisable. My signature below constitutes my acknowledgment that (1) I have read, understand and fully agree to the foregoing (2) Understand the caution and contraindications for each process and service proposed (3) Give consent to the proposed process that has been satisfactorily explained to me and I have all the information that I desire (4) I hereby give my consent and authorization voluntarily and release Forever Young Skincare and its agents of any claims that I have or may have in the future in connection with the described application or service.
Client full name*

First NameLast Name
Client signature*

Clear
Date*

MonthDayYear
Date
Witness full name (competed in salon)

First NameLast Name
Witness signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Forever Young Skincare

Health/Medical

Nutrition/Diet

Home Skincare Regimen

What are your goals and expectations?

Previous aesthetic treatments-check all that apply

Client Release