Skincare Intake Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) Occupation Emergency Contact(Required) Emergency Contact Phone(Required)Emergency Contact Relationship How frequently do you receive skincare services? First Time Once a year or less 2-3 times/year 4-6 times/yr 7-10 times/yr Monthly or more frequent Medical HistoryWhen was your last chemical peel? When was your last facial? Date of last facial hair removal Method of Removal Chemical Removal Laser Shaving Waxing Threading Other Are you currently or have you been under a physician/dermatologist care within the last year? Yes No If yes, when: Do you have recent cosmetic injectables/dermal fillers? Yes No If yes, which ones? FBotox/Xeomin/Jeuveau PRP/PRF Vollure/Voluma/Volbella Radiesse/Sculptra Other Date & placement of most recent injection Have you been diagnosed with cancer in the last 5 years? Yes No List all prescription drugs, shots, or creams you are currently using List all medical conditions you have Are you undergoing hormone replacement therapy? Yes No If yes, specify Do you have any allergies? Check all that apply(Required) None Nuts Soy Milk Latex Iodine Shellfish Lavendula Aluminum Fragrance Metals Latex Pollen Other Do you have or are you prone to? Ingrown Hairs Rashes/Eczema Scarring Athlete’s Foot Burns/Sunburns Bruising Hyper-pigmentation Open Wounds/Sores Have you used any of the following? Accutane Retin-A Alpha-Hydroxy Acid Glycolic Acid Resorcino Scrub /Peel Do you use a Tanning Bed? Yes No If yes, when and how often? Have you had recent natural sun exposure? Yes No If yes, when and how often? Have you used any other skin thinning medications? Yes No If yes, which ones? Do you use Retinol/vitamin A derivative products? Yes No If yes, Specify which kind & date of last use SKINCARE PRODUCTS YOU CURRENTLY USE DAILY/WEEKLYCleanser(s) Serums Toner Eye Serum/Cream Exfoliant Moisturizer SPF Other What type of skin do you have? Normal Dry Oily Combo Dry Combo Oily Acne Prone Sensitive What are your concerns today? Uneven Skin Ton Hyperpigmentation Melasma Blackheads Acne Fine Lines Wrinkles Dull/Dry Skin Rosacea Excessive Oil Dry Lips Dark Circles Relaxation Stress Relief FEMALE GUESTSAre you pregnant or trying to get pregnant? Yes No Are you lactating? Yes No Any recent changes to your contraceptive treatment? Yes No If yes, list name of contraceptive Are you taking oral contraceptives? Yes No If yes, specify: Are you going through menopause? Yes No If yes, list any issues you are having since this hormonal change: MALE GUESTSWhat is your current shaving system Wet shave Electric Disposable razor Laser Hair Removal Do you experience irritation from shaving? Yes No Do you get ingrown hairs after shaving? Yes No Consent(Required) I agree to the notice.My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I consent to photographs being taken to evaluate treatment efficacy and for social media use. No photographs revealing my identity will be used without my written consent. I hold harmless LaVida Massage, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen. If I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL.Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
