Skincare intake 201

Name __________________________________________________________________________________________ Address ________________________________________________________________________________________ City _____________________________________________ State ________________ Zip _________________ E-Mail __________________________________________________________________________________________ ___________________________Work______________________ Birthday ________________________________ Age ____________________________________________________ How did you hear about us? (If a friend, please give us their name so we can thank them!) Your Skin
Do you have any special skin problems pertaining to your face or body? If yes, please specify: ___________________________________________________________ Have you ever had problems with wax products? If yes, please specify: ___________________________________________________________ Do you experience skin breakouts? yes no Do you have a tendency toward redness? yes no What are your skin care goals? _____________________________________________________ Exfoliation History
Have you had a chemical peel, microderm, or any resurfacing treatment in the last month? yes no Do you use Accutane, Retin A, Renova, or any other prescription skin products? yes no Are you currently using any products that contain the fol owing ingredients? glycolic acid lactic acid exfoliating scrub hydroxy acid vitamin a derivatives Sun Exposure
What spf sunscreen do you use on your face?____body?____ Do you sunbathe or use tanning beds? yes no Allergies
Have you ever had an al ergy to nuts? ___________________
Have you ever had a reaction or an al ergy to any of the fol owing? cosmetics medicine iodine waxing products wheat algae extract Do you have al ergies to anything not listed above? ___________________________________________________ _____________________________________________________________________________________________ Your Health
Within the last year, have you been under a physician’s care? If yes, please specify: ___________________________________________________________________________ List any prescription or over-the-counter medications, supplements, vitamins, etc., taken regularly: ______________ ______________________________________________________________________________________________ Do you have metal implants, a pacemaker or body piercing? Female Clients Only
Are you pregnant or trying to become pregnant? I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. Please Note: Accutane, Retin A, Renova and anitbiotics can cause your skin to thin. Waxing and using
exfoliants while using these products can tear and could result in scaring. Please do not withhold this Information when asked by your Client Signature _________________________________________
Date ______________
This intake form is to correctly evaluate your special skin care needs. This information is confidential and may be disclosed only to staff members, risk or quality improvement personnel to assess the quality of care and wil not be passed on to a third party.

Source: http://www.sanavida.info/PDF%20Intakes/Skincare%20Intake.pdf