Total Skin & More, LLC: New Client Intake Form NEW

TOTAL SKIN & MORE, LLC

Holistic Skincare Company

(530)426-2756 | Total Skin & More, LLC |

totalskinmorellc.com
New Client Intake Form
Name*

First NameLast Name
Gender*
Phone Number*

Area CodePhone Number
Email*
Your Birthday*

MonthDayYear
Date
May we add you to our email list?
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
How do you prefer for Total Skin & More to contact you? *
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
FacebookInstagramGoogle SearchReferral (type name below)Other
How often do you receive facial/ skincare services?*
When was your last facial/ skincare service?*
Fine lines/ wrinklesAcneScarringDark spotsHyper-pigmentation/ Hypo-pigmentationAnti-agingOther
What are your current issues & how are they affecting you?*
Fine lines/ wrinklesAcneScarringDark spotsHyper-pigmentation/ Hypo-pigmentationNoneOther
Please list all medications:
Please list current daytime and night-time skincare routine:*
Do you have any special needs I should prepare for?
YesNo
Do you have an implanted electronic device in your body (like a Pacemaker, ICD, or medicine pump)?*
Are you currently pregnant?*
I am NOT taking any prescription medications.I just take Aspirin for my heart.I take a blood thinner medication.Other
Medical History: If you have experienced any of the symptoms that is marked with an asterisk (*), please call Ashley to discuss your medical history before booking an appointment; this is to ensure your safety and well-being.

Medical History*

Rows	Current	Past	Never
Pregnancy*
Blood Clots*
Pacemaker*
Congestive Heart Failure*
Unexplained Calf Pain*
Varicose Veins*
Stroke or Heart Attack*
Cancer*
Car Accident*
High Blood Pressure
Low Blood Pressure
Epilepsy / Seizures
Chronic Headaches / Migraines
Chronic Dizziness / Ringing Ears
Digestive Disease (IBS, Crohns, etc)
Chronic Constipation
Chronic Diarrhea
Kidney Disease / Chronic UTI's
Arthritis (rheumatoid, osteoarthritis)
Scoliosis / Kyphosis / Lordosis
Osteoporosis
Degenerative Spine / Disk
Broken Bone
Allergies that Require an Epi-Pen
Autoimmune Condition (Celiac, Hashimotos, Lupus, Graves, etc)
Diabetes / Insulin Resistance
Endocrine / Thyroid Condition
Chronic Depression
Chronic Anxiety
Chronic Swelling
Sensitive to Touch / Pressure
Easy Bruising
Shortness of Breath / Asthma
Chronic Muscle / Joint Stiffness
Chronic Muscle / Joint Pain
Chronic Pain
Chronic Numbness / Tingling
Neurological Condition (ALS, Parkinsons, etc)
Chronic Skin Rash
Highly Sensitive to Certain Smells or Fragrances
Fibromyalgia
Multiple Sclerosis
Memory Loss / Confusion

Cancellation Policies

100% Full Payment is required for the following conditions:
- No Show: If you do not show up for an appointment, you will not be refunded your depoist. A new depoist is due before your next appointment.
- Late Arrival: If you are 5 minutes late to your session you are requied to reschedule your appointment. Please plan to arrive 10 minutes early for your intial appointment.
- Last-Minute Cancellation/Reschedule: Failure to cancel or reschedule your appointment at least 24-48 hours in advance will result in a charge of 50% of the scheduled appointment fee. Payment is due before your next appointment.
Sickness Policy

Please reschedule your appointment as soon as you are aware of an infectious or contagious condition.

If you arrive for your appointment with symptoms of an illness, you must reschedule your appointment.

If you experience any of the following symptoms, you must reschedule:
- Fever or Chills
- Vomiting or Diarrhea
- Runny Nose
- Sore Throat or Cough
- You are currently taking an antibiotic.
- You have a skin infection like ringworm or athletes foot.
- You or someone in your direct care has a cold, sinus infection, or flu bug.
- You or someone in your direct care has been diagnosed with influenza (the flu).
Even if you are cancelling your appointment within the 24-hour notice period, the cancellation fee may be waived; the onset of symptoms doesn't always have great timing, right?
Informed Consent
By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for Total Skin & More, LLC in its entirety.

2. I fully understand all questions and information provided in the New Client Intake Form for Total Skin & More, LLC.

3. I have completed the New Client Intake Form for Total Skin & More, LLC accurately and to the best of my knowledge.

4. I have read and I understand the expectations and policies for Total Skin & More, LLC and I agree to the terms and conditions outlined.
Type Full Name:*

First NameLast Name
Signature*
Today's Date*

MonthDayYear
Should be Empty:

New Client Intake Form

By typing my first name, last name, and providing my e-signature below, I am indicating the following:

1. I have read the New Client Intake Form for Total Skin & More, LLC in its entirety.

3. I have completed the New Client Intake Form for Total Skin & More, LLC accurately and to the best of my knowledge.

4. I have read and I understand the expectations and policies for Total Skin & More, LLC and I agree to the terms and conditions outlined.