• Aesthetics Medical Intake Form

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do we have permission to contact you by phone or leave messages?
  • Do we have your permission to show your photos for educational purposes?
  • Are you pregnant and/or nursing?
  • What size robe do you need?

  • Concerns

  • What concerns you most about the overall appearance of your skin? (Check all that apply)
  • How would you describe your skin?
  • How would you describe your stress level?
  • Do you feel your stress level may be affecting the health of your skin?
  • Are you in good health overall?

  • History

  • Are you currently under the care of a physician?
  • Do you have any allergies to foods or medications?
  • Are you currently on any medications either topical or oral?
  • How do you heal after a breakout, cut, or scratch?
  • Do you smoke?
  • Are you prone to cold sores?
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  • Do you have an allergy to Latex?
  • Do you tan in the sun or in tanning beds/booths?
  • Please check the skincare products you are currently using:

  • By signing below, I acknowledge the answers I have provided are true and correct to the best of my knowledge.

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  • Aesthetics Informed Consent

  • I,     give my consent for this aesthetic procedure      to be performed by      .

  • I agree with

    • If I experience any pain or discomfort during the session, I will immediately inform the aesthetician so that the products and/or technique may be adjusted to my level of comfort.
    • I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
    • I understand that aestheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
    • I agree to keep the aesthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the aestheticians part should I fail to do so.
    • I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.

     Also I understand that;

    • The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future.
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  • Should be Empty: