Microdermabrasion Intake Form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you a student?

Yes

No

Have you ever experienced any of the following?

Cancer

High/Low Blood Pressure

Metal Implants/Pins Pacemaker/Defibrillator Diabetes

Claustrophobia

Heart Disease

Thyroid Disorder

Hysterectomy

Hormone Imbalance

Epilepsy/Seizures Blush/Redden Easily

AIDS/HIV

HepatitisA/B/C

Migraines/Headaches

Depression/Anxiety

Psoriasis

Rosacea

Eczema

Bruise Easily

Spinal Injury

Fever Blisters/Cold Sores

Immune Disorders

Lupus

Keloid Scarring

Blood Clot Disorder

Skin Disease/Disorder

Fibromyalgia

Menopause

Eating Disorder

Circulation Disorder

Other: _______________

Do you smoke?

Yes

No

Do you wear contact lenses? *

Yes

No

Are you under the care of a physician or dermatologist?

Yes

No

Any dermal injections/fillers within the last 6 months?

Yes

No

Are you using any products that contain: Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid,AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription skin products? *

Yes

No

Have you used any of the products listed above in the past 3 months? *

Yes

No

Have you ever had any of the following treatments? *

Facial

Body Wrap

Body Scrub

LED Waxing

Eyelash/Eyebrow Tinting Microdermabrasion

Chemical Peel

Dermaplaning

Laser Resurfacing

I have NOT had any of these treatments

Have you ever had any allergic reactions to any skin products? *

Yes

No

Do you wear sunscreen daily?

Yes

No

Are you currently or trying to become pregnant?

Yes

No

Are you currently lactating?

Yes

No

Any recent changes to/from your contraceptive treatment?

Yes

No

Please mark any that apply to you: *

Active infection (herpes, flat warts, etc)

Oral blood thinner medications

Active Acne

Rosacea

Sunburn

Pregnancy

Use of Retin-A, glycolic acids, etc.

Use of Accutane within the last year

Unmanaged Diabetes

Family history of scarring, hyper pigmentation, etc.

Eczema, dermatitis, psoriasis

Telangiectasia/ erythema

Cancer, chemotherapy or radiation Botox/fillers

Vascular lesions

Other conditions___________________

Please read and check each section: *

Prior to this treatment I have been candid in revealing any condition that may have a bearing on this procedure, such as pregnancy, recent facial peels, surgery, allergies, tendencies to cold sores, fever blisters and use of Accutane 4 weeks prior. Retinols and AHA’s have not been used 3 days prior to this treatment and will not be used within 3 days after treatment. Use of depilatories, waxing, electrolysis, laser hair removal, collagen injections stopped during the treatments and I will wait at least seven days after conclusion.

I have read and agree

*

I understand that no specific results are guaranteed with this procedure.

I have read and agree

*

I understand that pinkish and redness to the skin is very common and may last several hours and could persist for a few days. I understand that irritation may exist and I understand I should notify my skin care professional if irritation persists. Avoid any type of UVA/UVB exposure for at least 48 hours following this procedure. My skin will be delicate during this time, so I will and protect it from the sun by using a sunscreen an SPF 30 or higher on a daily basis. I will also keep the skin well moisturized.

I have read and agree

*

Acne Clients: I understand that I may experience a slight acne flare up, and that my acne condition may temporarily look worse for a few days after a microdermabrasion treatment. I agree to all of the above to have this treatment performed on me today and for all subsequent treatments. I do not hold my skin care professional responsible for any of my conditions that are present but not disclosed at the time of this skin care procedure. I will notify my skin care professional of any changes to my medical history or change in my skin care products. I will follow all prescribed directions post treatment.

I have read and agree

*

If I am unable to keep an appointment, I understand that 24-hour notice is required; otherwise I will be charged the cost of the session by whatever payment method is on file. If I decline to have payment on file, I am required to pay the 50% deposit each time I book an appointment.

I have read and agree

Client Consent: I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential. The treatments I receive here are voluntary and I release this institution and/or skin care professional from any liability and assume full responsibility thereof. *

First Name

Last Name