Simply Skin Las Vegas
Intake Form - Changes
Client's First/Last Name:
*
First Name
Last Name
Date:
*
/
Month
/
Day
Year
Date
PERSONAL INFORMATION CHANGES
Please select all that apply if have had any changes:
*
Address
Email
Emergency Contact
Name
Phone Number
Sex
N/a
MEDICAL/HEALTH CHANGES
Please select all that apply if have had any changes:
*
Health Changes
Sun Exposure/Tanning/Tanning Bed - LAST/NEXT 2 weeks
Treatments/Surgeries - LAST/NEXT 2 weeks
Injections/Fillers - LAST 2 weeks
Medications/Antibiotics/Vitamins
Products/Creams/Serums - IN TREATMENT AREAS
N/a
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
Legal Name Change
UPDATED NAME CHANGE (must match state issued ID)
Updated First Name
Updated Last Name
Legal Sex Change
UPDATED SEX CHANGE (must match state issued ID)
Email Address Change
UPDATED EMAIL ADDRESS
example@example.com
Contact Number Change
UPDATED PHONE NUMBER
Home Address Change
UPDATED HOME ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Change
UPDATED EMERGENCY CONTACT
First Name
Last Name
Phone Number
Relationship
ANY HEALTH CHANGES
Date:
/
Month
/
Day
Year
Date
Please list health changes:
SUN EXPOSURE / TANNING BED / TANNER
Exposure Date:
/
Month
/
Day
Year
Date
Type of Exposure:
Sun
Sun Bed
Spray Tan
Area(s)
TREATMENTS / SURGERIES
Date:
/
Month
/
Day
Year
Date
Please describe:
Area(s):
INJECTIONS / FILLERS
Date:
/
Month
/
Day
Year
Date
Please list type of injection/filler:
Please list area(s):
ANTIBIOTICS / MEDICATIONS / VITAMINS
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Medication
Prescribed/Taken for
Dosage (g,mg,iu)
Frequency
1
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Medication
Prescribed/Taken for
Dosage (g,mg,iu)
Frequency
2
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Medication
Prescribed/Taken for
Dosage (g,mg,iu)
Frequency
3
PRODUCTS / CREAMS / SERUMS
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Product/Brand
Usage/Description
1
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Product/Brand
Usage/Description
2
Start Date:
/
Month
/
Day
Year
Date
End Date (if known):
/
Month
/
Day
Year
Date
Name of Product/Brand
Usage/Description
3
Please hand the iPad to a Staff Member
Front Desk Signature
*
Client Signature
Submit
Should be Empty: