Facial Intake Form (word doc)

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Skin Care History
Name: ______________________________________________ Date: ____________
Address:
_____________________________________________________________
City: _________________________________ State: ___________ Zip: __________
Email Address: _________________________________________________________
Cell Phone: ____________________________ Date of Birth: ___________________
Emergency Contact: _____________________________ Phone: ________________
Are you pregnant: Yes  No 
If yes, how far along:
__________________________________
Do you have any of the following health conditions:
 AIDS/HIV
 Cancer
 Diabetes
 Heart Problems
 Hepatitis
 High/Low Blood Pressure
 Lupus
 Recent Surgeries
 Strokes
Please list any other health conditions not listed above: _______________________________________
_____________________________________________________________________________________
Are you currently using any of the following?




Retin A/Renova
Glycolic Acid/Alpha Hydroxy Acid
Accutane
Topical Vitamin C




Hydroquinone
Hormone Replacement Therapy
Birth Control Pills
Sunscreen/Sun Block
If yes, please list the names of any prescription medication(s): __________________________________
______________________________________________________________________________________
Are you using or have ever used any medications for acne?  Yes  No
If yes, how long has it been since you last used acne medication?_________________________________
Do you suffer from Cold Sores?  Yes  No If yes, do you take medication?  Yes  No
Do you smoke?  Yes  No
Do you tan?
 Yes  No
Have you had facials before?
 Yes  No
Have you had electrolysis, laser hair removal, or waxing in the last week?  Yes
 No
What skin care products are you currently using? _____________________________________________
______________________________________________________________________________________
Melt Massage & Facial Studio 01/2011
Page 1
Skin Care History Cont.
Have you ever had an allergic reaction to any of the following?




Cosmetics
Medication
Food
Animals




Sunscreens
Iodine
Pollen
Skin Products



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Essential Oils
Nuts
Alpha Hydroxy Acids
Fragrance



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Shellfish
Latex
Aspirin
Other
If yes to any of the above, please explain ___________________________________________________
_____________________________________________________________________________________
Have you had any of the following?
 Cosmetic Surgery
 Botox Injections
 Skin Cancer
 Dermatitis
 Keloid Scarring
 Laser Resurfacing
 Chemical Peels
 Other _____________
If yes to any of the above, please state when your last treatment was:
___________________________
What areas of concern do you have regarding your skin?




Breakouts/Acne

Blackheads/Whiteheads 
Excessive Oil/Shine

Rosacea

Broken Capillaries
Sun/Liver/Brown Spots
Enlarged Pores
Uneven Skin Tone



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Sun Damage
Wrinkles/Fine Lines
Dull/Dry Skin
Flaky Skin
 Dehydrated
 Other ______________
Is there any other information I should know before beginning your treatment? _____________________
______________________________________________________________________________________
It is your responsibility to inform Maria Keith of any pre-existing and all health conditions. It is also your
responsibility to inform Maria Keith of any discomfort during any session.
I _____________________________ understand and accept any risks of which I have been advised
associated with the agreed upon skin treatment. I release Maria Keith from all liability arising from any
injury and/or damage from failure to inform Maria Keith of any pre-existing conditions, limitations,
specific sensitivities, and/or any discomfort during the treatment. I agree to keep Maria Keith updated as
to any changes in my medical profile.
Client Signature: ____________________________________
Date: ____________________________
Parent or Guardian: _________________________________
Date: ____________________________
Melt Massage & Facial Studio 01/2011
Page 2
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