Microsoft word - 2. skin care intake form.doc

Skin Care Information Form

Date ________________ Date of Birth ________________ Gender ( ) Male ( ) Female
Name ______________________________________ Member #______________________
(If you are not a member of the University Club please complete the following information)
Address ___________________________________________________________________
City _______________________ State ________________ Zip Code __________________
Phone __________________________ Other _____________________________________
Email Address ________________________ Referred By ____________________________
Emergency Contact ___________________ Emergency Contact Phone _________________

Medical Background
Please List any skin or health conditions you are experiencing _________________________
___________________________________________________________________________
___________________________________________________________________________
Have you ever taken or currently taking: ( ) Retin A ( ) Accutane
Are you currently taking any oral or topical antibiotics: ( ) Oral ( ) Topical
What is the name of the antibiotic _______________________________________________
How often do you exercise? _______________
What is your level of stress? Low 1 2 3 4 5 6 7 8 9 10 High
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? _______
Do you smoke? ( ) Yes ( ) No
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
Do you have any of the following: Scars ( ) Stretch Marks ( ) Hyper Pigmentation ( )
Do you suffer from:
( ) Acne ( ) Blackheads ( ) Whiteheads ( ) Milia
( ) Oiliness ( ) Dehydration ( ) Eczema ( ) Cellulite
( ) Psoriasis ( ) Vein/Circulation Problems
Have you ever received any of the following treatments:
( ) Facial ( ) Microdermabrasion ( ) Laser Surgery ( ) Chemical Peels
( ) Waxing ( ) Lash/Brow Tint ( ) Laser Hair Removal ( ) Vein Treatments
Please select the box that applies to you:
( ) I never Tan ( ) I tan with difficulty ( ) Average tanning, sometimes burn
( ) Easily tan, rarely burn ( ) I never burn
Client Informed Consent to Treatment I, _______________________________ consent to and authorize the University Club to perform skin exfoliation, skin waxing, body treatments and other related skin care services. Services: ____________________________________________________________ • I have not used a scrub, Retin A, take home micro-dermabrasion or glycolic peel in the last 72 hours. ______ (initial) • 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. ______ (initial) • Possible side effects to chemical peels include, but are not limited to: Mild redness, dry skin and flaking. Most side effects are temporary and generally fade within 72 hours. ______ (initial) • I have no allergies to Iodine (Seaweed). ______ (initial) • I am not Epileptic and do not have heart or circulation problems. ______ (initial) • 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. ______ (initial) • I agree to adhere to all safety precautions and home skin care program as recommended by my University Club esthetician. ______ (initial) • I am over 18 years of age, or I have a parental consent co-signed below. ______ (initial) • I will call to inform the University Club of any complications or concerns I may have as soon as they occur. ______ (initial) • I have been off Accutane for at least 12 months. ______ (initial) • 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. ______ (initial)
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.
Client name (Signature): ________________________________ Date: ________________
Treatment of a minor:
Signature of parent or guardian: ______________________________ Date: _________________

Source: http://www.universityclubofmsu.org/files/2.%20U-Club%20Skin%20Care%20Intake%20Form.pdf