Acne Bootcamp Intake Form

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Date of Birth *

Date

Occupation*

Today’s Date*

Date

How did you hear about us?*

Please list ALL medications, supplements/daily vitamins, birth control, or herbal remedies you currently take - don't leave anything out!:*

Do you consume marijuana or THC? If so, what form? (smoke, gummies, etc) How often do you consume if so?*

Please list allergies or sensitivities:*

Please list Injuries or surgeries:*

Do you have any underlying medical conditions your provider should be aware of?*

Do you have regular periods?*

YesNoN/AOther

Are you going through menopause?*

YesNoN/A

Have you ever received professional skin care treatments - if yes please list when your last treatment was (not including with Aesthetics by Tay)?*

What are your specific concerns at this time regarding your skin/what you want to change? Please list your goals for the appointment.*

What do you consider your skin type?*

How often do you do a skincare routine?*

I do not have a skincare routine.Every am/pm daily.When I remember to.Rarely, I do not like doing a skincare routine.

Do you ever skip your am or pm routine? If so, what steps are you skipping, and how often are you skipping them?*

Please submit a photo of ALL skincare products you currently use grouped together.*

Browse Files

Please submit a photo of ALL makeup products you currently use grouped together. *

Browse Files

How often do you wear makeup products?*

I do not wear makeup products.I wear makeup products daily.I wear makeup products occasionally.

Please submit a photo of the toothpaste you currently use. *

Browse Files

Please submit a photo of any hair care products you use, including shampoo / styling products.*

Browse Files

Do you wash your hair morning or night, and how often?*

Do you sleep with wet or dry hair?*

Do you sleep with hair pulled back or down?*

Pulled backDownN/A

How often do you wash pillowcases and makeup brushes/sponges?*

Do you use makeup sponges, just brushes, or both? (Or not applicable)*

Do you wear spf every day?*

YesNo

Have you ever been treated for a skin condition? If yes, what condition, and how was it treated?*

Please check all that apply.*

Have you received any medical aesthetic treatments in the last 6 months? (botox, filler, etc.) If so, when?*

What does your breakfast, lunch, dinner, and snacks look like on a day to day basis?*

Do you go to Starbucks regularly, or anything similar? What is your typical drink order? *

Do you consume energy drinks? Which ones?*

Do you consume alcohol? If yes, how often?*

Do you consume protein shakes, bars, greens powders or take creatine?*

Do you consume eggs? Egg whites only, whole egg, both? How often?*

Do you smoke/vape?*

YesNo

Do you have to work night shift?*

Do you play sports/workout regularly? If yes to either, what is your schedule like for these? If you play a sport, what sport?*

Do you use fabric softener or dryer sheets?*

YesNo

What detergent do you wash linens/clothing in?*

Do you swim in a chlorinated pool?*

YesNo

What is your stress level right now?*

LowAverageSomewhat StressedVery Stressed

How do you manage stress, if at all?*

What is your sleep schedule? How many hours of sleep do you get each night?*

Do you use a tanning bed?*

YesNo

Do you squeeze/pop/self extract breakouts? (be honest lol!)*

YesNo

If yes to above question, do you squeeze/pick...*

Almost every dayOnce or twice a weekSeldom

How do you extract/pick at breakouts?*

With an extractor toolWith fingersWith q-tipsOther

Check the statement that applies most to you*

I tend to pick at lesions deliberately in front of a mirrorI pick unconsciously without noticing until laterOther

Mark any statement you feel that applies to you*

Acne causes me to feel depressed quite oftenAcne causes me to feel depressed only occasionallySometimes I call off social engagements when I have an acne flareEven though my acne makes me self conscious, I never cancel social plans because of itI do not avoid people because of my acneI have trouble looking people in the eye when I talk to themI feel that people stare at my acneI hate looking in the mirrorI do not consider my acne unusual - I don't think other people judge me because of it.

Any comment or observation you wish to make about acne's emotional effect on you?

Please submit 3 photos of only your full face in frame taken in NATURAL lighting with no makeup applied. (Left side , center, and right side) *

Browse Files

Do you give permission for photos to be taken of your skin and/or shared on social media? (including photos shared in email check ins) *

How hopeful do you feel about starting acne bootcamp?*

Very hopeful & excited!Hopeful, but not excited.Somewhat hopeful.Not hopeful, and very hesitant to do this.

By SUBMITTING THIS FORM, you agree to the following:
3) I understand that the therapist or esthetician does not diagnose illnesses or injuries, or prescribe medications.
4) I have clearance from my physician to receive acne treatments.
5) I understand the risks associated with acne treatments include, but are not limited to:
• Superficial redness
• dyness/flaking
• irritation

I, therefore, release Aesthetics by Tay and the individual esthetician from all liability concerning these injuries that may occur during the session.
6) I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let the aesthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
7) I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so she may adjust
accordingly.
8) I understand that I or the esthetician may terminate the session at any
time.

POLICIES:

You must cancel/reschedule within 24 hours or you are charged 50% of your service fee. No exceptions.

No call - No shows are charged 100% of their service. No exceptions.

If you need to reschedule or cancel, please click the link in your confirmation text or email and it will prompt you to do so.

When you book an appointment, you check the box that states you agree to these policies.

Please do not bring guests to your appointment, unless approved otherwise. This includes children.

Location: 151 WENDOVER DRIVE, Kingsport TN 37663. Please arrive ON TIME, not late or early.

Please DO NOT wear makeup to your appointment as this takes away from the full time of your service.

Thank you!

Signature*

Acne Bootcamp Client Form

Intake Information

Medications/allergies/surgeries

Skin History

Product Usage

Contraindications

Lifestyle