Client Intake Form

Todays Date

MonthDayYear

Name*

First NameLast Name

E-mail*

Date of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

What is your main skin care goal?*

What products are you currently using at home?*

Are you currently pregnant or lactating? *

YesNo

Are you currently undergoing cancer treatments?*

YesNo

If yes, please provide any additional information on your current treatment plan. This information is helpful in creating a skincare treatment plan while undergoing your cancer treatment.

Are you current under physician care for any skin related issues? *

YesNo

If yes, what are you being treated for?

Are you currently on any prescription medications orally or topically? .*

YesNo

If yes, what medications are you currently using:

Have you had any of these health conditions in the past or present?*

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid?*

Yes, currently usingYes, but not within the last 30 daysNot using any of these ingredients

Have you ever experienced claustrophobia?*

YesNo

Have you had any Botox, Fillers or Injectables in the past 30 days? *

YesNo

Are you allergic to?*

If you checked yes to any of these, please list your allergy.

I understand that this is a cosmetic treatment and that no claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.

I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience actual immediate results with this procedure, as each case is individual.

I understand that there is some degree of discomfort. (warming, tenderness, dryness, superficial flaking, etc) I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact Beautiful You.

I agree to refrain from tanning or excessive sun exposure while I am undergoing treatment and 14 days after my treatment. I understand that direct sun exposure is prohibited while I am undergoing treatment and that the use of sun block protection with a minimum SPF 30 is mandatory. I have revealed any medical conditions that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels or surgery, types of contraindicated medications such as Accutane, hormone replacement therapy or use of Retin-A. Contraindicated medications should be discontinued seven days prior to the treatment with exception of Accutane which must be discontinued for six months prior.

I have not had an invasive treatment of any kind within 14 days of my treatment. Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure as outlined. I will also inform Beautiful You of any changes in my medical history, current medications and/or any changes relevant to this procedure prior to any future treatments.

I Agree

Signature of person undergoing treatment OR Signature of Guardian if person is under 18 Years of Age.