Corrective Skin Care Intake Form

Corrective Skin Care Intake Form
Full Name*
Phone*
Date of Birth*

MonthDayYear
Date
Address*
City*
State*
Zip*
Email*
example@example.com
How did you hear about us?*
What skin concerns brings you to our practice?*
Please describe your current skin care routine with products listed*
Medical History Do you currently or have you had any of the following? Please check all that apply:

AcneActive InfectionAIDS/HIVAlopeciaAutoimmune DisorderBleeding DisorderBlistering SunburnsCancerCirculation ProblemsCold SoresDiabetesEczemaEpilepsyHeadaches/MigrainesHepatitisHigh/Low Blood PressureHormonal ImbalanceHype/Hypo ThreadLupusPigmentation DisorderPsoriasisRashesSkin CancerShinglesUnusual Moles
IF you checked any of the above, please explain
Are you taking any medications currently*
Are you or could you be pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Do you suffer from photosensitivity?*

YesNo
Do you have a history of easy/excessive hyperpigmentation?*

YesNo
Have you ever had an adverse reaction to cosmetic treatments?*

YesNo
Do you form keloid scars?*

YesNo
Are you exposed to the sun on a daily basis*

YesNo
Are you planning a vacation in the next 3-6 months?*

YesNo
Do you use tanning beds?*

YesNo
Have you recently had a chemical or glycolic peel?*

YesNo
Do you have any other allergies*

YesNo
Have you had any facial or dermatology service in the past 30 days?*

YesNo
Have you had any permanent or semi-permanent makeup services completed previously?*

YesNo
Have you used Accutane, Retin-A, Renova, AHAs, or Retinal products in the last twelve months?*

YesNo
Have you received Botox, Lip Fillers, Restylane, Juvederm, or Collagen injections in the last 6 months?*

YesNo
IF yes to any of the above, please explain
By signing below, l agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
Signature*

Clear
Date*

MonthDayYear
Date
I hereby grant and authorize Health and Glow LLC and my service provider the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me or my minor child) to be saved for progress notes and/or for any lawful promotional materials including but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration This authorization extends to all languages, media, formats, and markets now known or later discovered I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, waive any right to royalties or other compensation arising or related to the use of my image or recording I hereby hold harmless and release Health and Glow LLC and my service provider from all liability, petitions, and causes of action which I. my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.
Signature*

Clear
Name Printed*
Minor Child
Date*

MonthDayYear
Date
Should be Empty: