New Client Intake Form

New Client Intake Form

Skin Health + Facial Consent
Name:*

First NameLast Name
Today’s Date:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Phone Number:*
Date of Birth:*

MonthDayYear
Date
Occupation:*
Emergency Contact & Relation to Contact:*
Emergency Contact Number:*
Please enter a valid phone number.
How did you hear about us?:*

Facebook/InstagramOnline SearchReferral
If referred, by whom?:
Massage pressure (neck, shoulders, arms, hands):
Please approximate your preferred massage pressure (included in most facial services over 60 minutes).
Medical History

+ Lifestyle & Stress Analysis
Are you currently under the care of a physician?

YesNo
Have you experienced any of these health conditions in the past or present? Check all that apply:*

Hormone ImbalanceCancer/Systemic DiseaseHigh Blood PressureDiabetesHeart ConditionArthritisAutoimmune DisorderAsthmaEpliepsy/SeizuresCold SoresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesLow Blood PressureHigh Blood PressureKeloid ScarringNoneOther
Any known allergies?:*

AsprinLatexFruitsShellfishLidocaneFragrance/Essential OilsTree NutsDairySunscreenPollenNoneOther
If Other, please list:
Include any skin treatment products you have used that caused an unexpected reaction or side effect.
List medications/supplements you are currently taking:
Those listed may be factors or contribute to skin conditions
Have you ever received any botox or fillers? If so, where and when?:
Due to cosmetic work, some provided services may not be performed, ie facial massage.
If you are currently experiencing or being treated for any health or skin-related condition/disorder, please describe:
Have you ever experienced claustrophobia?*

YesNo
Please rate your stress level.*

LowMediumHighNone
How much water do you drink daily?:*
How much sleep do you get on average, a night?:*
Please indicate the following that apply to your eating habits. Check all that apply:

Fast FoodBaked BreadSeafoodDairy ProductsPeanut Butter/Peanut ProductsPre-Workout Supplements
Your Skin

Self-Analysis
What are your skin concerns?:*
What would you say your skin type is?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
Which of the following best describes your skin type? (Please select one type number):

I - Always burns, never tans.II - Always burns, sometimes tans.III - Sometimes burns, always tans.IV - Rarely burns, always tans.V - Brown, moderately pigmented skin.VI - Black skin.
What is your ancestry, if known? (African, Asian, European, Middle Eastern, etc.):
This will help indicate your Fitzpatrick Skin Type.
What skin care products do you use on a daily basis?:*

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSPFVitamin A (retinol)None
For the products check-marked, please list the brand and whether you use it AM or PM:
Be as specific as you can.
Do you experience routine breakouts or acne?

YesNo
Have you ever been diagnosed with eczema, psoriasis or rosacea?

YesNo
Have you received any of these facial hair removal services in the last 7 days?

Waxing/sugaringThreadingLaser/Electrolysis
Do you currently use:

Accutane/IsotretinoinCortisoneHydroquinoneBenzoyl PeroxideTretinoin/Retin-AMetrogelDifferinEpiduoTazoracFinaceaAczoneSpironolactoneDoxycyclineClindamycinWinleviAzeleic Acid
What condition were you treating with this medication, and when was the last time it was used?:
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?:

YES, within the last monthYES, within the last 2-3 monthsNO
Do you…

Wear contact lensesHave a pacemakerHave metal implantsSmoke/Vape tobaccoConsume THCConsume AlcoholConsume CaffeineFrequent tanning beds
Hormone History

Female clients or for those on hormones
Are you taking birth control?:

YesNo
Are you pregnant or breast-feeding?:

YesNo
Are you going through menopause or perimenopause?:

YesNoNot Sure
Are you currently on any type of hormone therapy control?:

YesNo
If Yes, please describe:
Client Consent
I have answered the above questions truthfully and to the fullest extend of my knowledge, and I understand and agree that I am ultimately responsible for payment in full for consultation and/or services received.

YesNo
I consent to "before and after" photos for the purpose of documentation, potential advertising, and promotional purpose.

Yes to all.Documentation only.
POLICIES & CANCELLATION:

I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 48 hours notice. Failure to do so will result in the loss of deposit. I acknowledge that ANY no show will flag my account and future appointment requests may be automatically rejected by the booking system. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “No-show” policy.
POST-SERVICE + AFTERCARE

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF15), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (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. I give consent for all future treatments

I release Roots Esthetics and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
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New Client Intake Form

Medical History

Your Skin

Hormone History

Client Consent