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?*

YESNO

Do you ever experience skin breakouts?

YESNO

Do you ever experience oily shine throughout the day?

YESNO

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

YESNO

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?

YESNO

Do you exercise regularly?

YESNO

Do you follow a restricted diet?

YESNO

Do you wear contact lenses?

YESNO

Do you have metal implants, pacemaker or body piercings?

YESNO

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

Are you pregnant or trying to become pregnant?

YESNO

Are you taking oral contraceptives?

YESNO

Are you lactating?

YESNO

Do you experience irritation from shaving?

YESNO

Do you experience ingrown hairs?

YESNO

Are you currently having or due for your menstrual period?

YESNO

Have you started any new medication since your last visit?

YESNO

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?

YESNO

Do you sunbathe or use tanning beds?

YESNO

Do you burn easily in moderate sunlight?

YESNO

Do you blush easily when nervous?

YESNO

Do you have a tendency to redness?

YESNO

Do you suffer from sinus problems?

YESNO

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