Client Health Intake Form

Today's Date

Date

First Name

Last Name

Street

Apt. #

City

State

Zip

Dermatologist/Physician

Emergency Contact

Your occupation

E-Mail

Skin Care Professional Name

1. What is the reason for your visit today?

2. What special areas of concern do you have?

Expectations and History:

3. Which conditions would you like to improve?

4. Have you ever had facial treatments in the past, yes or no? What was your experience?

5. How would you describe your skin?

6. How would you rate your skin?

7. Do you ever experience flakiness, tightness, redness, or excessive oily shine during the day? If yes, explain below.

8. What is your present skin regimen?

Please list the brands and as much detail about the products you selected above.

9. Are you ever exposed to chemicals, oils, or other substances that may aggravate your skin? If yes, what are they?

10. Do you blush easily? If yes, what are the contributing factors?

11. Do you sunbathe or use a tanning bed? If yes, how often?

12. Have you ever had peels, microdermabrasion, facial surgery, cosmetic surgery, botox, collagen injections, laser resurfacing? How recently? Provide details.

13. Are you under treatment for any current skin condition? If yes, what conditions?

14. Do you bruise easily? Yes or no?

15. Do you get sores/blisters (Herpes Zoster/Shingles)?

16. Does your skin heal quickly or slowly? Do you scar or get pigmentation in the healing process?

18. What medications/hormone replacement/vitamins do you presently take?

19. Have you ever used topical antibiotics? If yes, when and for how long?

20. Any personal or family history of skin cancer? Provide detail.

21. How would you describe your overall health?

22. Have you ever had any of the following, past or present?

If you selected any of the above, provide details.

23. Do you smoke?

24. Do you wear contact lenses?

25. Have you ever had a reaction to the following?

26. Are you pregnant or trying to get pregnant?

27. Do you take oral contraceptives?

28. Do you experience hormone imbalance?

29. Are you going through any fertility treatments?

Lifestyle and Diet:

What is your stress level?

Do you exercise regularly?

How many glasses of water do you consume daily?

How many cups of caffeine beverages (coffee, tea, soft drinks) do you consume daily?

Are you following any special diet? If yes, please explain.

Your practitioner will recommend the appropriate schedule for future focial treatments or physician referral in order to achieve your skin improvement gools.

Iblanks, do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care.I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, will inform my skin care professional immediately.

I release and hold harmless the skin care professional Ayesha Yousuf, The Facial Corner Inc., and the staff harmless from any liability for adverse reactions that may result from this treatment.

Policies

1. We require 24-hours notice for cancellations. If you do not come to your appointment or give 24-hours notice, your deposit will not transfer to your next appointment.

2. If you are not satisfied with your service or products, please contact your skin care professional within 24- hours ofter your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.

I have read and understood all of the foregoing information.

Client Signature

Date

The Facial Corner Inc.

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

INFORMED CONSENT RELEASE