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Skincare Intake Form

First Name
Last Name
Date of Birth
Street
Apt. #
City
State
Zip
Phone – Home
Work
Mobile
Dermatologist/physician
Phone
Emergency Contact
Phone

Email

Referred by
FriendMailerWalk-byE-mailGift CertificateOther

Other

Skin Care Professional Name:

What is the reason for your visit today?

What special areas of concern do you have?

EXPECTATIONS and HISTORY

Which conditions would you like to improve?

Acne scarringAcneAge spotsEnlarged PoresFine lines & wrinklesHyperpigmentationBroken CapillariesStrectch MarksSurgical/Facial scarsOther

Other

Have you ever had facial treatment in the past?
YesNo

What was your experience?

How would you describe your skin?
NormalDryOilyCombinationSensitiveSun Damaged

How would you rate your skin?

Do you ever experience
Flakiness?Redness?Tightness?Excessive oily shine during day?

What is your present skin regimen?
Soap and water onlyMoisturizerCleanserExfoliationTonerSun Block every dayMasqueOther

Other

Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?YesNo

If yes, what are they?

Do you blush easily? YesNo

If yes, what are the contributing factors? EmotionsFoodsTemperature changesOther

Other

Do you Sun bathe?Use a tanning bed?

How often?

Have you ever had PeelsMicrodermabrasionFacial surgeryCosmetic SurgeryBotoxCollagen InjectionsLaser resurfacing

How recently?

Are you under treatment for any current skin condition? YesNo

If yes, what?

Does your skin heal FastScarsPigments

Do you bruise easily? YesNo

Do you get sores/blisters (Herpes Zoster/Shingles)? YesNo

What medications/hormone replacement/vitamins do you presently take?

Have you ever used Accutane©Retin-A®Renova®Topical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy Acids

If yes, when and for how long?

Any personal or family history of skin cancer? YesNo

Provide detail

How would you describe your overall health? ExcellentGoodFairPoor

Have you had any of the following, past or present?

Acne YesNo
When
Allergies YesNo
Arthritis or Bursitis YesNo
Blood Pressure HighLowNormal
Breast Implant YesNo
Cancer YesNo
CataractsYesNo
Cholesterol HighLowNormal
Claustrophobic YesNo
Diabetes YesNo
Diarrhea/constipation YesNo
Eczema YesNo
Where
Epilepsy YesNo
Hay Fever YesNo
Headaches YesNo
How Often
Heart Disease/Conditions YesNo
What
Hepatitis YesNo
HIV/AIDS YesNo
Infections YesNo
Lupus YesNo
Menopausal YesNo
Metal Implants YesNo
Pace Maker YesNo
Phlebitis YesNo
Serious Injury YesNo
What
Sleep problems YesNo
Thyroid HighLowNormal
Varicose Veins YesNo
Do you smoke? YesNo
Do you wear contact lenses? YesNo

Have you ever had a reaction to CosmeticsMetalsMedicationFoodFragranceAirborne particlesOther
Explain

FOR WOMEN:

Oral contraceptives? YesNo
Are you pregnant or trying to get pregnant? YesNo
Are you taking hormone replacement? YesNo
Do you experience hormone imbalances? YesNo

FOR MEN:

Do you shave with Electric shaver?Razor?
Do you experience skin breakouts? YesNo
Do you have ingrown hair? YesNo

LIFESTYLE & DIET

Is your stress level HighMediumLow
Do you normally sleep well? YesNo
Do you regularly exercise? YesNo
Do you have food intolerances? YesNo
Do you follow any special diet? YesNo

How many glasses of water do you consume daily?

How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
1 - 3 cups4 or more

In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you?
YesNo

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.

INFORMED CONSENT RELEASE

I , do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold harmless the skin care professional, Lorraine ‘RAIN’ Tabraham-Winter, LMT, Esthetician, SET, CFT, CPT; Rain's Therapeutic Massage & Skin Care, Inc., and the staff harmless from any liability for adverse reactions that may result from this treatment.

POLICIES

1.We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before.
2.If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.