Skincare Form

Hello and welcome! Please complete this Intake to the best of your ability, and in it's entirety.

All information is held in the strictest confidence. Thank you and I look forward to meeting you!

Name*

First NameLast Name

Client Birthdate*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

How did you learn of M Esthetics? Referred by?*

How may we contact you? (Check all that apply)*

PhoneTextEmail

Are you currently under the care of a physician?*

YesNo

If yes, what conditions?

Are you currently taking any medications? If yes, please list medication and dosage per day*

Do you have any allergies? Please list.*

Are you pregnant? *

YesNo

Have you been treated for? *

List other

Are you concerned about skin conditions on your skin/body?(Check all that apply)*

List other

Have you received any of the following procedures in the last month?*

List any cosmetic procedures you have had in the last 12 months.

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? Or any skin thinning product or drug, including Alpha/Beta Hydroxy Acids and Benzyol Peroxide? *Important for Hair Removal, Peel/Microdermabrasion Services.*

YesNo

Do you have any metal implants in your body?*

YesNo

If yes, where?

On a scale of 1-10, please rate how you feel about the health of your skin.*

Do you wear facial sunscreen daily?*

YesNo

Describe your daily skin care routine.*

Desired results you'd like to see in your skin?*

Would you like your email added to my mailing list for specials and events?*

YesNo

I understand and agree the information I provided above is true and correct. I also understand that all information stated is strictly confidential and will not be shared outside this facility due to HIPPA regulations. Please Note, that waxing can have certain side effects such as skin removal, redness, swelling, tenderness. I take every precaution to avoid any reactions, it is equally important that you inform me of any change in medication or topical treatment prior to starting any treatment. I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my skin therapist to perform services as we have discussed and will hold her harmless from any liability that may result from this treatment.

I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I'm currently taking/using topically. I understand the esthetician will take every precaution to minimize or eliminate negative reactions. I have read and understand the post-treatment care instructions (If applicable). I'm willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home/post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify I have read, and fully understand the above. I understand the procedure and accept the risks. I do not hold the esthetician (Monica Torres/M Esthetics), responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Signature*

Skincare Form

Medical & Skin History