Skincare Information Intake Form

Skincare Information Intake Form
Name*
Date of Birth*

MonthDayYear
Date
Address*
Phone*
Format: (000) 000-0000.
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Number*
How did you hear about us?
Medical History
Please list any skin or health conditions you are experiencing
Retin AAccutaneOral AntibioticsTopical Antibiotics
If you are currently taking antibiotics, what is the name?
How often do you exercise?
What is your level of stress?
How many hours of sleep do you get per night?
How many 8 OZ glasses of water do you drink a day?
How many ounces of caffeine do you consume each day?
YesNo
How much UV exposure do you get (sun tanning beds, commuting in car)?
Please list all supplements medications allergies or recent surgeries
Client Self Assessment
ScarsStretch MarksHyper Pigmentation
AcneOilinessPsoriasisBlackheadsEczemaWhiteheadsCelluliteDehydrationMiliaVein/Circulation Problems
FacialWaxingLash/Brow TintMicrodermabrasionLaser SurgeryLaser Hair RemovalChemical PeelsVein Treatments
I never tanEasily tan, rarely burnI tan with difficultyI never burnAverage tanning, sometimes burn
Client Informed Consent to Treatment
I consent to and authorize The Sweet Escape Spa to perform skin exfoliation, hair removal, body treatments, relaxation therapies and other related skin care services.
- I have not used a scrub, Retin A or glycolic peel in the last 72 hours.
- I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.
- Possible side effects to chemical exfoliants include, but are not limited to: Mild redness, dry skin and flaking. Most side effects are temporary and generally fade within 72 hours.
- I am not Epileptic and do not have heart or circulation problems.
- It is recommended to discontinue use of all AHA’s, Glycolics, Retin A, Renova, or any exfoliating products for up to 72 hours post clinical procedure. Using hydrating, soothing, antioxidants for healing. No sun exposure or tanning beds for up to 72 hours and use at least SPF 15 sunscreen daily when receiving treatments is recommended.
- I agree to adhere to all safety precautions and home skin care program as recommended by my esthetician.
- I am over 18 years of age, or I have a parental consent co-signed below.
- I will call to inform The Sweet Escape Spa of any complications or concerns I may have as soon as they occur.
- I have been off Accutane for at least 12 months.
- The nature and purpose of the treatment has been explained to me, and any questions I may have regarding this procedure has been explained to my satisfaction.
Please initial here to confirm that you agree with the consent statements above:*
- I have voluntarily elected to undergo this treatment/procedure after its nature and purpose has been explained to me, along with the risks involved. Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks and complications. I also recognize there are no guaranteed results and that independent results are dependant upon age, skin condition and lifestyle.
- I have read and understand the post-treatment home care instructions. I have also to the best of my knowledge, given accurate account of my medical history.
- I have read and fully understand this agreement and all information detailed above. I do not hold esthetician responsible for any of my conditions that were present, but not disclosed at the time of the procedure, which may be affected by the treatment performed today.
Signature*
Date*

MonthDayYear
Date
Signature of parent or guardian (if you are consenting for the treatment of a minor)
Date (if you are consenting for the treatment of a minor)

MonthDayYear
Date
Should be Empty:

Skincare Information Intake Form

Medical History

Client Self Assessment

Client Informed Consent to Treatment