Pre-Treatment Forms

Please complete and submit each form below prior to arriving for your first appointment. If your technician requires additional information, they will reach out to directly.

Feel free to contact us with any questions or concerns.

What type of skin do you have?

Skin Conditions:

What are your top 3 skincare concerns?

Have you ever been diagnosed with cancer? (if yes, list last treatment date)

Current Medications:

Prescription Topicals:

Skin Conditions:

List Last Treatement Date & Any Complications

Describe your skins care routine:

I agree that the nature and purpose of the treatment has been explained to me, and any questions I have regarding the treatment have been explained to my satisfaction.

I understand that with any treatment certain risks are involved and that any complications from known or unknown causes could occur.

I understand that possible side effects include, but are not limited to: mild to moderate redness, mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic reactions. Most side effects are temporary and will dissipate within 3-7 days.

I do not have active cold sores.

I will call to inform my skincare professional of any complications or concerns I may have as soon as they occur.

I understand that it is recommended prior to having a facial infusion to not have used Retin A for 48 hours, Accutane in 6 months, or have waxed 24 hours prior to receiving treatment.

Do you currently have or have you ever been diagnosed with any of the following?

Do you have any allergies?

Do you have any metal implants?

Please list all current or previously diagnosed skin conditions

Check all that apply:

Check all that you are sensitive to:

How would you describe your skin?

Sensitive Resilient Not Sure

I have completed these forms to the best of my ability and knowledge and agree to inform my Esthetician of any changes to the information listed on all the pages of this client intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my Esthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my esthetician and Skintology Apothecary for any injury or damages incurred due to my misrepresentation of my health history.

Pre-Treatment Forms

Pre-Treatment Forms

Client Information Form

Medical History Form

Phone

Email

Location