Aesthetic Intake Form

Aesthetic Intake Form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
What is your Gender? *

Female Male
Date of Birth *

Month Day Year
Date
Emergency Contact *
Emergency Contact Phone Number *
Medical

Health History
Within the last year, have you been under the care of any physician, dermatologist, or other medical professional? If yes, please explain: *
Within the last year, have you had any laser or resurfacing treatments? If yes, please specify treatment and treatment date: *
Have you had any anti-wrinkle injections or injectable fillers? If yes, please specify: *
List any medications, antibiotics, supplements, or herbal/homeopathic remedies you currently take: (oral or topical)? *
How long have you utilized the medication(s) selected above? *
Please check if you have recently experienced or presently have any of the following conditions: *

Asthma Cardiac Problems Diabetes Eczema Epilepsy Fever Blisters Chronic Headaches Hepatitis Herpes High blood pressure Hesterectomy Immune Disorders Lupus Mental Disorder Metal bone, pins or plates Pacemaker Psychological disorder Sinus problems Skin Diseases Urinary or kidney problems N/A
Are you currently using blood thinners? *

Yes No
Do you wear contacts? *

Yes No
Do you smoke? If yes, specify frequency and quantity: *
Do you drink alcoholic beverages? If yes, specify frequency and quantity: *
How many glasses/cups of water do you drink daily? *
Do you have any skin conditions on your face or body such as psoriasis or eczema? If yes, please explain: *
Are you pregnant? *

Yes No N/A
Are you taking birth control pills? *

Yes No N/A
Are you currently under hormone replacement therapy? *

Yes No
On a scale of 1-10, how would you rate your current stress level? *
(low) 1 2 3 4 5 6 7 8 9 10 (high)
Skin
What is the reason for your visit today? *
What special areas of concern do you have? *
How would you rate the overall quality of your skin? *

Poor Fair Good Very Good Excellent
Please select your skin type: *

Normal Dry Sensitive Oily Combination Acne Prone
What improvements would you like to see to your skin? *

Hydration Tone Balance Oil Preventative Maintenance Clear Acne Breakouts Smooth Lines and Wrinkles Lift and Firm Allergy Relief

What type of skincare products do you currently use? *

Name

Frequency: Daily, Weekly, Monthly

A.M./P.M.

Cleanser

Soap

Toner

Moisturizer

Serum/Treatment

Mask

Sunscreen

Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? If yes, please explain: *
Do you have acne? If yes, what is the frequency? *
Do you use sunscreen? *

Yes No
Do you have a tendency to redness? *

Yes No
Do you ever experience skin breakouts? *

Yes No
Do you ever experience oily shine during the day? *

Yes No
Do you experience frequent blemishes? *

Yes No
Do you experience these conditions on your skin? *

Flakiness Tightness Sensitivity None
Please check any medications that you are currently using (or used in the past): *

Azelaic Differin Renova RetinA Tazarac Glycolic Alpha Hydroxy Acids Accutane
Do you ever experience a reaction to any of the following? *

Cosmetics Fragrance Hydroxyl acids Sunscreens None
Do you have any allergies including cosmetics, foods or drugs (topical or oral)? If yes, please specify: *
Returns, Refunds and Cancellation Policy: All sales are final. Store credit is provided for services not rendered. All products purchase is final. A 24hr cancellation notice is required in order to avoid a fee which will equal the half of the amount of service scheduled.

PHOTOGRAPHIC CONSENT: I, hereby authorize and consent that any and all photographs, Images, or videos taken by Detoxity Spa of any part of my body, whether originals or reproduction, may be utilized for such purposes as desire in exhibited and published through any medium whatsoever as part of or in connection with professional activities, even though such use may be for advertising purposes of trade. This consent is not retractable, either by oral foregoing and any photographs, image, or videos taken for future procedures.
I undetstand that the services offered are not a substitute for medical care, and any infonnation provided by the consultant or technician are for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the consultant and technician in giving better service and is completely confidential.
Signature *

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Aesthetic Intake Form

Medical

Skin