CLIENT IN-TAKE FORM Please feel free to contact me if you have any questions about the following forms. Send me an email Give me a Call Name * First Name Last Name Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Age * Date of Birth * Refered by * Reason for todays visit. * What is your occupation? * Does your employment or hobbies require you to be in the sun? * Yes No If yes please describe: Which best describes your skin WITHOUT sun exposure: * White White to Cream Cream to Beige Olive, Light Brown Dark Olive, Brown Black How does your skin tan? * Always burn. Never tan. Always burn. Tan minimally and with difficulty Burn minimally. Tan gradually and uniformly Burn minimally. Always tan well. Barely burn. Tan very well. Never burn. Tan deeply. Describe your heritage/ethnic background: * Natural Hair Color * Black, Dark Brown, Light Brown, Chestnut, Auburn, Red / Copper, Strawberry Blond, Golden Blond, Light Blond, White, Gray Which best describes your natural eye color? * Amber (golden or copper color without flecks of blue or green) Blue Brown Gray Green Hazel (green or blue with flecks of gold or copper) Pink / Red What is your current skin care routine? * Choose any that apply. Cleansers Scrubs Anti-aging Serums Exfoliating Serums Face Masks Moisturizers Sunscreen What is your current brand of skin care? * Do you partake in any at-home/DIY skin care treatments as seen on social media? * Yes No If yes, please explain why. Are you currently using or have you used any of the following for acne in the past year? * Antibiotics Accutane Retin-A - Tretinoin Tazorac Differin - Adapalene Other None of the Above If yes to the question above: Please explain the use for each product, how long you have been using it and when you last used the product. Have you used any "over the counter", or RX forms of RetinA or Retinol? * Yes No If yes, please list the brand and last date of use. Do you use any skin care products or make-up that contain the following? * Salicylic Acid Benzoyle Peroxide Lactic Acid Glycolic Acid None Do you take any medications or supplements? * Yes No If yes, please list any medications or supplements and prescribed use. Do you take birth control? * Yes No If you take birth control, what is the brand? Are you pregnant? * Yes No Are you lactating? * Yes No Do you have or have you ever had any of the following? * Cancer Cold Sores Sunburns Herpes HIV / AIDS Eczema Psoriasis Dermatitis Hives / Welps Gluten Sensitivity Diabetes Keloid Scarring Autoimmune Disease None of the above. If you answered yes to Cancer above, please list the type, treatment and date of last treatment. Are you a smoker? * Yes No How often do you consume alcohol? * Daily Weekly Less None of the above. How often do you exercise? * 1 - week 3 - week 5 - week More None of the above If yes to exercise. What type of exercise do you partake? How many hours of sleep do you average each night? * How would you rate your stress level? * No stress Mildly stressed Stressed Overly stressed Are you allergic or sensitive to any of the following? * medications foods supplements herbs essential oils products product ingredients aspirin latex other: None of the above If you answered yes to above question please list them and your reaction in detail below. Do you currently receive any of the following facial treatments? * Facials Chemical Peels Enzyme Treatments Microdermabrasion Dermaplaning Botox / Fillers None of the above. If yes to any listed or not listed above, please explain and give approximate date of last service: Check any of the following that you feel applies to your skin and what you would like addressed * Oily - Dry Water - Dry Oily - Acneic Blackheads Sensitive Milia Hyperpigmentation Melasma Hypo-pigmentation Fine lines + Wrinkles Environmentally damaged Rosacea Sagging/slackness Large Pores Other None of they above. If you checked other above, please describe below. I agree that the information I have provided is accurate and up-to-date, and that truthful answers to all of these questions is used solely in a manner that will provide me with the safest, most comfortable, and most beneficial treatment possible. I understand that these treatments are not medical and fall under the realm of Cosmetic Arts as defined by the State of North Carolina. I also understand that I could experience certain side effects including but not limited to pinkness of treated area, tenderness, dryness, tightness, breakout from pore purging, flaking, or allergic reaction. I agree that I will notify Michelle Parent of Skin Joy, LLC if I have questions or concerns. My signature designates that I absolve from all liability, both personally and professionally, Michelle Parent of Skin Joy, LLC and Sandra York, owner of Serenity Spa & Wellness * Yes No Thank you!
