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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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Hours

Monday: 10:00AM-5:30PM
Tuesday: 10:00AM-5:30PM
Wednesday: Closed
Thursday: 10:00AM-5:30PM
Friday: 10:00AM-5:30PM
Saturday: 10:00AM-5:30PM
Sunday: Closed
Call or Text * +1 (415) 309-8925

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San Francisco Esthetics
126 Serramonte Center Studio 12 Daly City, CA 94015

Phone: +1 (415) 309-8925

Email: info@sanfranciscoesthetics.com

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Cancellation Policy
Privacy Policy
Returns and Refunds

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