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Free Mini Facial
Client Consent Form
Hydrafacial Consent Form
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Home
Services
Hydrafacial
Forms
Free Mini Facial
Client Consent Form
Hydrafacial Consent Form
Testimonial
Contact
Home
Services
Hydrafacial
Forms
Free Mini Facial
Client Consent Form
Hydrafacial Consent Form
Testimonial
Contact
Menu
Home
Services
Hydrafacial
Forms
Free Mini Facial
Client Consent Form
Hydrafacial Consent Form
Testimonial
Contact
Client Intake Form
Client Intake Form
Must be Completed 48hours prior to Appointment
Preferred Contact Method
Phone
Email
Text
1). Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Yes
No
2). Any recent surgery, including plastic surgery?
Yes
No
3.) have you had any skin cancer?
Yes
No
4). Have you had any recent cosmetic piercings on the face, or permanent make-up i.e. microblading of eyebrows, eye liner etc.
Yes
No
5.) have you ever had any of these health conditions in the past or present? (please check all that apply and provide additional information in the space provided)
Cancer
High Blood Pressure
Spinal injury
Hysterectomy
And active infection
Hear Problem
Arthritis
Asthma
Insomnia
Eczema
Seizure disorder
Hormone imbalance
Systemic disease
Thyroid condition
Diabetes
Headaches (chronic)
Varicose Veins
Epilepsy
Lupus
Fever Blisters
Any Active Infection
Psychologic
Herpes
Frequent cold sores
Keloid scarring
Immune Disorders
HIV/AIDS
Hepatitis
Skin lesions or skin disease
Blood clotting abnormalities
Phlebitis, blood clots, poor circulation
Metal bone pins or plates
6.) Do you Smoke?
Yes
No
7.) do you follow a regular exercise program?
Yes
No
8.) do you follow a restricted diet?
Yes
No
9.) What Is Your Stress Level?
High
Medium
Low
10.) Do You Use Retin-A, Renova, Adapalene Hydroxyl Acid, Glycolic Acid, Aha, Salicylic Acid, Retinol/Vitamin A Derivative Products?
No
Yes
11.) Have You Used Any Of These Products In The Last 3 Months?
No
Yes
12.) Have You Used An Acne Medication?
No
Yes
13.) Do You Form Thick Raised Scars From Cuts Or Burns?
No
Yes
14.) Do You Have Hyperpigmentation (Darkening Of The Skin) Or Hypopigmentation (Lightening Of The Skin) Or Marks After Physical Trauma?
No
Yes
15.) Do You Experience Any Problems Sleeping?
No
Yes
17.) Do You Suffer From Sinus Problems?
No
Yes
18.) Have You Ever Had Any Adverse Reaction After Using Any Skin Care Product Such As: Rash, Irritation, Peeling, Sun Sensitivity Or Breakout?
No
Yes
19.) Female Only - Are You Taking Oral Contraceptives:
No
Yes
20.) Female Only - Any Recent Changes To Your Oral Contraceptives?
No
Yes
21.) Female Only - Are You Pregnant Or Tryig To Become Pregnant?
No
Yes
22.) Female Only - Are You Lactating?
No
Yes
23.) FEMALE ONLY - ANY MENOPAUSE PROBLEMS?
No
Yes
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