Client Facial Intake & LiabilitY Name * First Name Last Name Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Medical History * Please check all that apply Acne Arthritis Asthma Bleeding Disorder Cancer/Chemotherapy/Radiation Cardio Vascular Issues Dermatitis Diabetes Depression Easily Bruises/Sensitive Skin Eczema Epilepsy/Seizures Fatigue Fever Fungal Condition Headaches/Migraines Heart/Liver/Kidney Disease Hepatitis High Blood Pressure HIV Hives/Herpes/Shingles Hyper/Hypo Thyroid Hypertension Inflammation Insomnia Keloid Scarring Loss of Sensation Low Blood Pressure Lupus Organ Failure Metal Implants Pre-Cancerous Lesions Pregnant/Breast Feeding Psoriasis Rashes Recent Surgical Incisions Respiratory Conditions Seborrhea Sinus Infection Skin Cancer Skin Condition/Disorder Stress Stroke Surgery Transplants(s) Unhealed Wounds Vertigo/Dizziness Warts Watery Eyes/Seasonal Allergies Other N/A Are you currently taking any medication? * Yes No If yes, please explain: Do you have any allergies? * Yes No If yes, please explain: Are you currently being treated for any conditions by a physician or dermatologist? * Yes No If yes, please explain: Please describe your skin type: * Normal Oily Dry Combination Sensitive Have you had any facial or dermatology services in the past 14 days? (Ex: laser treatments, chemical peels, etc.) * Yes No If yes, please explain: Have you used any facial or dermatology services in the past 4 weeks? Yes No If yes, please explain: Have you used any Retin-A, AHA's, or Retinol/Vitamin A products in the last 5 days? * Yes No If yes, please explain: Have you had any Botox, Restylane, Juvederm, or Collagen injections in the last 14 days? * Yes No If yes, please explain: Any history of Acctuane (isotretinoin) use? * Yes No If yes, please explain: Do you frequently use tanning beds or have had any excess sun/UV exposure within the past 4 weeks? * Yes No If yes, please explain: Please list the products you are currently using in your skincare routine (be as specific as you can with brands and names): * Skin Concerns * Please check all that apply Acne Blackheads Broken Capillaries Comedones Cysts Oily Skin Dryness/Dull skin Eczema Fine Lines/Wrinkles Hyperpigmentation Sagging Discoloration Milia Psoriasis Redness Rosacea Scarring Under eye puffiness, dark circles, wrinkles Sensitivity Sun Damage Do we have you permission to take photographs of your skin for progress pictures and/or social media? * Yes No Thank you!
