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Esthetics by Alicia
New Client - Intake Form
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I understand that the form I am required to acknowledge is on the previous page. *Your progress will not be saved. Please go back now to review the Client Consent & Acknowledgment form.
I understand that I will lose my progress. I found the required form.
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Today's Date
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Last name
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First name
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Birthday
Month
Month
Day
Year
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Phone
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Email
Address
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Emergency Contact Name & Phone Number
Have you experienced coughing and/or fever in the last 72hrs?
Yes
No
Are you currently under the care of a physician for ongoing medical treatment?
Yes
No
Are you trying to get pregnant or lactating?
Yes
No
Are you taking oral contraceptives?
Yes
No
Are you currently under the care of a Dermatologist?
Yes
No
If yes, please list the provider's information:
Do you have any of the following medical conditions?
Arthritis
Blood Clotting Abnormalities
Cancer
Diabetes
Frequent Cold Sores
Option 6
Hepatitis
Herpes
High Blood Pressure
HIV / AIDS
Hormone Imbalance
Keloid Scarring
Rosacea
Seizure Disorder
Skin Cancer
Skin Disease / Skin Lesions
Thyroid Imbalance
Are there any conditions I should be aware of?
For each condition marked above, please indicate the date of diagnosis.
Have you had any surgery where lymph nodes were removed?
Yes
No
Have you had an allergic reaction to any of the following?: (please mark all that apply)
Food
Latex
Asprin
Lidocane
Hydrocortisone
Hydroquinone
Skin Bleaching Agents
Please list any further allergies here:
Describe the reactions of your allergies:
Have you ever had a skin reaction to a fragrance?
Yes
No
Dislike any fragrances?
Yes
No
Do you have a pacemaker?
Yes
No
Topical Steroids use?
Yes
No
Do you use sunscreen?
Yes
No
Sunbathe, Tanning beds, Self Tanner or Lotions?
Yes
No
Did you use Retin-A, Renova, AHA, Retinal, or any other Vitamin A derivative Products?
Yes
No
Have you ever used Accutane?
Yes
No
Have you used any of the following for hair removal in the last six weeks?
Shaving
Waxing
Electrolysis
Plucking / Tweezing
Threading
Depilatories
Natural Fillers (ex Hyaluronic Acid, Collagen etc.) in the last 3-4 weeks?
Yes
No
Synthetic Fillers ( ex silicone)?
Yes
No
Neurotoxin injections in the last 3-4 weeks?
Yes
No
Have you ever had Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Yes
No
If yes, please describe below:
Have you had any of the following done in the past?
Botox, Collagen (fillers)
Laser hair removal
Permanent Make-up
Microdermabrasion
Chemical Peels
Jet Plasma
Which of the following best describes your skin? Note more specification in “Please note any skin concerns”
Very Oily
Dry
Combination
Sensitive
Please note any skin concerns here:
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I have read, understand, and agree with the Client Consent & Acknowledgment form
Yes, I understand
If under 18 years of age parent(s)/guardian must sign below:
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I acknowledge that I will make informed decisions regarding my treatment after being fully informed of my options. I consent to this treatment and agree to follow all post-treatment and aftercare instructions as directed.
I understand and agree
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I certify that all information I have provided is true and accurate, and I understand that providing false or incomplete information may affect my results and increase the risk of side effects. * Signature
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Submit
Intake Start
* Client Consent & Acknowledgment Form *
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