Client Intake Form and Medical History

In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All Information is confidential.

First Namerequired
Last Namerequired
Date of Birthoptional
Phone (Digits Only)required


Occupationtextoptionaldb save

How were you referred to us?textoptionaldb save

Medical History

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Are you currently under the care of a physician for any reason?
If yes, for what?textoptionaldb save

List all medications, supplements, and Vitamins:textoptionaldb save

List allergies:textoptionaldb save

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Have you taken or been administered Accutane in the last 6 months?

Antibiotics:textoptionaldb save

Birth Control pills:textoptionaldb save

Check All That Apply:

Aspirin, ibuprofen use
Retin-A, Tretinoin
Matrigel, Metro Cream
Glycolic acid on a regular basis
Sun reactions
Medication allergies
Food allergies
Aspirin allergy
Latex allergy
Lidocaine allergy
Hydrocortisone allergy
Hydroquinone allergy
Smoking history
Cold sores, herpes
Bleeding disorders
Autoimmune, HIV
Pregnant or planning to be
Implants of any kind: Dental, Breast, Facial
Migraine headaches
Thyroid Imbalance
Seizure disorder
Active infections
Radiation in the last three months

Skin Conditions: (Check All That Apply)

Keloid Scarring
Tattoos, perm makeup, and microblading

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Skin/laser treatments at another office
If yes, when?textoptionaldb save
Results:textoptionaldb save

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If yes, when?textoptionaldb save
Results:textoptionaldb save

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If yes, when?textoptionaldb save
Results:textoptionaldb save

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Hair Removal
If yes, when?textoptionaldb save
Results:textoptionaldb save

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Chemical peels
If yes, when?textoptionaldb save
Results:textoptionaldb save

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Sun exposure/tanning bed in last week? Self Tanner?
If yes, when?textoptionaldb save
Results:textoptionaldb save

List Medical issues not listed above:textoptionaldb save

Current Sin care and lifestyle

1. How do you wash your face?

2. If soap, what brand?textoptionaldb save
3. If cleanser, what brand?textoptionaldb save

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4. Do you use a moisturizer?

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5. Are you on a special diet?
If yes, please specify?textoptionaldb save

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6. Do you consume water daily?
If yes, how much?textoptionaldb save

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7. Do you drink coffee, tea, or soda daily?

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8. Do you exercise?
If yes, how often?textoptionaldb save

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9. Have you ever had a facial?
If yes, when was your last facial?textoptionaldb save

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10. Do you give yourself facials at home?
If yes, how often?textoptionaldb save

11. List additional cosmetics and skin care products you are currently using:textoptionaldb save

What is the primary reason for your visit today? (Select all that apply in the list below)

I’m concerned about facial or body hair and would like information on ways to get rid of it.
I’m concerned about fine lines around my eyes
I’m concerned about scowl lines when I frown
I’m concerned about pigmentation or age spots
I’m concerned about broken capillaries on my face or spider veins on my legs.
I’m concerned about skin laxity and sagging
I’m concerned about the lines around my mouth
I’d like more defined lips
Other (Please list skin concerns below)
Othertextoptionaldb save

I certify that preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical and health conditions and to update this information at subsequent visits. A current history is essential for the provider to execute appropriate treatment procedures. I have signed the consent form for this procedure. I had the opportunity to ask questions prior to the treatment. I accept arbitration as a means of resolution for practice liability.

Date: 4/14/2021

Time: 3:04 PM

Client Signaturerequired
Tap to Sign

Contradictions & Best Practices for High Frequency Machines

Client Initialsrequired

High Frequency should not be used on clients with the following conditions or devices

  • Couperose skin
  • Inflamed areas
  • Pacemakers
  • Metal implants
  • Heart problems
  • High blood pressure
  • Braces
  • Epilepsy
  • Pregnancy

Body piercings from the waist up; the client should avoid any contact with metal such as chair arms, jewelry, and metal Bobby pins during the treatment; a burn may occur if such contact is made

Adhere to the following guidelines

To avoid being burned, the client should avoid contact with metal during electrical machine treatments

Clients should remove all jewelry and piercings prior to the treatment

The technician should ground their finger on the electrode prior to applying it to the group the client and prior to removing it from the client

The electrode should always be continuously moving

Electrodes should be gently removed from the handpiece to avoid snapping the electrode

Missions & Best Practices for The Galvanic Machine

Client Initialsrequired

To avoid potential health complications, do not use Galvanic Current on clients with the following conditions:

  • Metal Implants
  • Braces
  • Heart conditions
  • Epilepsy
  • Pregnancy
  • High blood pressure
  • Diminished nerve sensibility
  • Open or broken skin
  • Couperus skin or rosacea
  • Chronic migraine headaches

Apprehension about the use of electrical appliances

Contradictions & Best Practices for The Vacuum Machine

Client Initialsrequired

Vacuum machine should not be used on Couperose skin with distended or dilated capillaries or an open lesions to avoid harming the client skin, do not use suction or inflamed, rosacea, or couperose skin.

  • General contradictions for electrotherapy
  • Heart conditions
  • Pregnant
  • Epilepsy seizure line frayed of electrical current
  • Opener broken skin

Contradictions & Best Practices for LED Therapy

Client Initialsrequired
  • Pregnancy
  • Open or identified skin lesionsSeizure disorder
  • Auto immune disorder
  • Taking photosensitive medications
  • Led are using facials for approximately 15 minutes

Running Late: We understand things happen, if you are running late we will still take you in, but to be fair to all of our clients that showed up on time we will have to cut your service short to stay on schedule for everyone. You will also be responsible for the total cost of your booked appointment that you were late for.

All Appointment Cancellations are to be cancelled no less that 12 hours before appointment start time. Every infraction that is cancelled after the 12 hour period there will be a 40% of the scheduled service(s) fee. If you no call/no show you will be held liable for 80% of the services you were scheduled to receive and the Credit Card you have on file with us will be charged. By you making this appointment you are accepting and agreeing to all of our terms.

Date: 4/14/2021

Time: 3:04 PM

Client Signaturerequired
Tap to Sign

I would like to get a copy of this document. I confirm my email address is spelled correctly.
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By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions available at and . You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.

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