Elev8skin ~ Client Intake Form

* Iphone users: "view desktop version" at bottom of page*
Please Fill out Before your Appointment
Full Name: *
Date of Birth: *
Email address: *
Best Phone # to reach you: *
Referred by: *
Emergency Contact: *
Please list All Skincare Products you are Currently using on your Face: *
Please list any health conditions you are experiencing: *
Are you taking: *
If you are taking Retin A......for how long and how often. Doctor prescribed? *
If you are taking Antibiotics, what is the name? *
How often do you exercise? *
# of hours of sleep per night? *
What is your level of stress? *
How many glasses of water do you drink each day? *
How much caffeine do you consume each day? *
How much alcohol do you consume each day? *
Do you smoke? *
Please list all supplements, medications, allergies or recent surgeries: *
How much UV exposure do you get? (sun, tanning beds, commuting in car) *
Which applies to you? *
Do you have any of the following: *
Do you suffer from: *
Have you ever received any of the following treatments? Facial - Microdermabrasion - Laser Surgery - Chemical Peels - Waxing Lash/brow tint - Laser hair removal - Vein treatments **Please specify most recent: *
Are you allergic to any foods, fruits, vegetables, plants? Please Specify: *
Are you allergic to Latex? *
What are you wanting to address today? *
**If you are not getting a Microcurrent Treatment, you may skip to "Medications/Sensitivity" below...**
Have you ever had skin cancer? Please specify when: *
Are you currently free of cancer? *
Do you have diabetes? *
Do you have frequent headaches? *
Are you pregnant? *
Are you currently trying to get pregnant? *
Do you suffer from Arthritis? *
Are you wearing contacts? *
Are you wearing dentures? *
Do you have a Pacemaker? *
Do you have metal implants? *
Do you have cardiac or circulatory problems? If yes, Please specify: *
Do you have high blood pressure? If yes, Please specify: *
Are you currently taking any prescription or over the counter medications? If yes, please list all oral medications you are taking. *
Do you suffer from Epilepsy or seizures? *
Have you ever had surgery? If Yes, Please specify.. *
Have you had Botox or Fillers recently? Please specify date: *
Do you have Vericose veins? If Yes, Please specify.. *
Do you have any contagious diseases? If Yes, Please specify.. *
I Certify that I am not HIV positive, have AIDS or Hepatitis C ~ initial please: *
Do you have osteoporosis? *
Do you have Autoimmune disorder? Is it under control? Please specify: *
Have you had Shingles? When? *
Have you had any broken bones in the past 2 years? *
Do you experience back pain? Please specify: *
Have you been in an accident or had any injuries in the past 2 years? *
Do you have tension or soreness anywhere? Please specify *
**Medication & Sensitivity/ Skin Conditions: Certain medications, cosmetics or skin conditions may produce a greater sensitivity to the procedure. It is not recommended to undergo therapy if you have been diagnosed with a physical condition affecting the skin. As for medications or cosmetics, typically, these products feature a warning label to notify you of potential adverse affects. Please consult a physician prior to therapy if you are using any such products or medications or have a history of skin problems or believe your skin to be reactionary. *
Waiver and Release: I acknowledge that my use of the therapy is undertaken at my sole risk. Any change in physical activity or routine are done so voluntarily with the complete understanding that I am responsible for all actions and assume all risks of injury, illness, or disease, etc. I acknowledge that I have carefully read this waiver and that I fully understand that this is a release of liability. I agree to release and discharge the business, and all its affiliates, agents, employees, representatives, successors, or assigns, from any and all claims or causes of action. This release supersedes all other signed release forms and shall be considered retroactive to the first date of equipment usage. By signing this release I acknowledge that I understand its content and that this release cannot be modified orally. *
Name and Date below: *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.