Substance Intake Form

Name

First NameLast Name

E-mail

Phone Number:

Area CodePhone Number

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date:

MonthDayYear

Where did you hear about us?

If you have any allergies, please specify.

Have you had a chemical peel in the last 6 months?

Do you ever experience skin breakouts?

Do you ever experience oily shine throughout the day?

Do you ever experience a burning, itching sensation on your skin?

If you've ever experienced a reaction to any skin care products, please specify.

If you have been under a dermatologist or physicians care within the last year, what was it for?

If you've undergone any surgeries in the last 2 years, please specify.

Have you ever had any health problems past of present? If yes, please specify.

Do you smoke?

Do you exercise regularly?

Do you follow a restricted diet?

Do you wear contact lenses?

Do you have metal implants, pacemaker or body piercings?

Please list any medications, supplements, vitamins, diuretics, etc. that you take regularly.

Are you pregnant or trying to become pregnant?

Are you taking oral contraceptives?

Are you lactating?

Do you experience irritation from shaving?

Do you experience ingrown hairs?

Are you currently having or due for your menstrual period?

Have you started any new medication since your last visit?

Do you have any special skin problems pertaining to your face or body? If yes, please explain.

What skin care products are you currently using?

Soap Cleanser

Toner/Moisurizer

Masque

Exfoliator

Eye Products

Other

Do you currently use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products? If yes, please list:

Are you currently using any products that contain the following ingredients? (select all that apply)

If you've ever had a chemical peel, microdermabrasion or any resurfacing treatments, please specify how long ago.

How much water do you consume daily?

How many alcoholic beverages do you consume weekly?

Do you even experience flakiness and/or tightness?

Do you sunbathe or use tanning beds?

Do you burn easily in moderate sunlight?

Do you blush easily when nervous?

Do you have a tendency to redness?

Do you suffer from sinus problems?

What skin type do you feel you have? (click all that apply)

What are your skin care goals today?

If I experience any pain or discomfort during this session, I will immediately inform the esthetician so that the session may be adjusted to my level of comfort. I further understand that esthetics should not be considered as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, or other qualified medical specialist for any mental or physical ailment that I'm aware of. I understand that licensed estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness, and nothing that is said in the course of the session given should be constructed as such. Because esthetics should not be performed under certain medical conditions, I affirm that I have stated all knon medication conditions, and answered all questions honestly. I agree to kep Substance of Taos and the esthetician updated as to any changes in my medical profile and understand that there shall be no liability on Substance of Taos and the esthetician's part if I fail to do so.

Client Initials (in lieu of electronic signature)

Date

MonthDayYear

Substance Skin Treatment Intake Form

Your Skin