Substance Intake Form

Name *

First Name Last Name

E-mail *

Phone Number: *

Area Code Phone Number

Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Birth Date:

Month Day Year

Where did you hear about us?

A Friend or colleauge Google Blog Post Social Media Other

If you have any allergies, please specify. *

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

YES NO

Do you ever experience skin breakouts?

YES NO

Do you ever experience oily shine throughout the day?

YES NO

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

YES NO

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?

YES NO

Do you exercise regularly?

YES NO

Do you follow a restricted diet?

YES NO

Do you wear contact lenses?

YES NO

Do you have metal implants, pacemaker or body piercings?

YES NO

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

Are you pregnant or trying to become pregnant?

YES NO

Are you taking oral contraceptives?

YES NO

Are you lactating?

YES NO

Do you experience irritation from shaving?

YES NO

Do you experience ingrown hairs?

YES NO

Are you currently having or due for your menstrual period?

YES NO

Have you started any new medication since your last visit?

YES NO

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)

Glycolic Acid Lactic Acid Exfoliating Scrubs Hydroxy Acids Vitamin A Derivatives

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?

YES NO

Do you sunbathe or use tanning beds?

YES NO

Do you burn easily in moderate sunlight?

YES NO

Do you blush easily when nervous?

YES NO

Do you have a tendency to redness?

YES NO

Do you suffer from sinus problems?

YES NO

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

Oily Dry Aging Combination Sensitive Rosacea

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 *

Month Day Year

Substance Skin Treatment Intake Form

Your Skin