Microsoft word - client intake form2 - bodywrap and facial.docx
Please complete the following information if you are receiving a Facial, Body Wrap or Skin Care treatments: Name: ___________________________________________________________________________________ Your Skin:
1. Do you have any special skin problems pertaining to your face or body?
If yes, please specify: _________________________________________________________________________
2. Do you suffer from any of the following:
Acne – where? _____________________________________
Exfoliation History:
Other resurfacing treatments: ______________________________________________________If yes, were they in a medical setting?
2. Are you taking or using, or have used any of the following prescriptions or medications in the last six months?
Other prescription skin products: ___________________________________________________
3. Are you currently using any products that contain the following ingredients?
4. Are you allergic to any topical substances?
_______________________________________________________________________________
Moisture Hydration:
1. Do you ever experience these conditions on your skin? Flakiness Tightness Obvious Dryness
Where? When? _____________________________________________________________________________
Capillary Activity:
1. Do you burn easily in moderate sunlight?
Oil Secretion:
1. How late in the day do you experience oily shine? __________________________________________________
2. Where and when do you experience skin breakouts? ________________________________________________
Nerve Activity:
1. Do you ever experience a burning, itching sensation on your skin?
Where/When? ______________________________________________________________________________
3. What type of massage pressure do you prefer?
4. Have you ever had a reaction to any of the following?
Other: ___________________________________________
1. Following a waxing treatment have you experienced any of the following?
2. Do you have any skin sensitivities, irritants or rashes? ___________________________________
NOTE: Do not expose skin to the sun/indoor tanning for at least 48-hours after the waxing service. Female Guests:
1. Are you pregnant or trying to become pregnant?
Misc. Info:
1. What are your skin care goals? ________________________________________________________________
__________________________________________________________________________________________
2. What results would you like to focus on today? ____________________________________________________
__________________________________________________________________________________________
Skin Examination: (For Esthetician Use only)
Sup. Wrinkles: ____________________ Deep Wrinkles: ____________________ Skin abnormalities: _________________________________________________________________ Scars: _____________ Date: ____________
Size: _______________ Color: _______________
Pigmentation Spot: _________ Size: ____________________ Color: _____________________ Professional Observation: _________________________________________________________________ ______________________________________________________________________________________
CONSENT TO MICRODERMABRASION TREATMENT PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS BY SIGNING BELOW I, __________________________________ , acknowledge and agree to hold Alamo Hills Advanced Aesthetic & Laser Center and any of its employees harmless against any and all liability and claims for any injuries or any other occurrence
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