Intake Form
Date:
*
/
Month
/
Day
Year
Date
Name (must match your state issued ID):
*
First Name
Last Name
PERSONAL INFORMATION CHANGES
1. Have you had any changes to the following personal information since you were last here?
*
Yes
No
Address
Email
Emergency Contact
Name
Phone Number
Sex
MEDICAL/HEALTH CHANGES
1. Have you had any changes to your health since you were last here?
*
Yes
No
2. Have you or will you tan within the NEXT/LAST 2 weeks via SUN, SUN BED, or SPRAY TANNER in areas being treated?
*
Yes
No
3. Have you had or will you have any other TREATMENTS/SURGERIES in the area(s) we are treating in the last/next 2 weeks?
*
Yes
No
4. Have you had any INJECTIONS or FILLERS in the area(s) we are treating in the LAST 2 WEEKS?
*
Yes
No
5. Have you started/stopped ANY medications, antibiotics, or vitamins since you were last here?
*
Yes
No
6. Are you using any NEW skin care products, creams, or serums in the AREAS WE ARE TREATING since you were last here?
*
Yes
No
ACKNOWLEDGMENT I certify that my medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the staff of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
*
Client Signature
Please hand the iPad to a Staff Member
Staff - Initial for Personal Info Change
*
Staff - Initial for Health Change:
Staff - Initial for Sun Exposure:
Staff - Initial for Treatments/Surgeries:
Staff - Initial for Injections/Fillers:
Staff - Initial for Medication Change:
Staff - Initial for Products Change:
SSLV Staff Signature
Front Desk Signature
*
Staff Signature
Submit
Should be Empty: