Elev8skin ~ Client Intake Form

* Iphone users: "view desktop version" at bottom of page*
Please Fill out Before your Appointment
Full Name: *
Your answer
Date of Birth: *
Your answer
Email address: *
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Best Phone # to reach you: *
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Referred by: *
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Emergency Contact: *
Your answer
Please list All Skincare Products you are Currently using on your Face: *
Your answer
Please list any health conditions you are experiencing: *
Your answer
Are you taking: *
If you are taking Retin A......for how long and how often. Doctor prescribed? *
Your answer
If you are taking Antibiotics, what is the name? *
Your answer
How often do you exercise? *
Your answer
# of hours of sleep per night? *
Your answer
What is your level of stress? *
How many glasses of water do you drink each day? *
Your answer
How much caffeine do you consume each day? *
Your answer
How much alcohol do you consume each day? *
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Do you smoke? *
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Please list all supplements, medications, allergies or recent surgeries: *
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How much UV exposure do you get? (sun, tanning beds, commuting in car) *
Your answer
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: *
Your answer
Are you allergic to any foods, fruits, vegetables, plants? Please Specify: *
Your answer
Are you allergic to Latex? *
Your answer
What are you wanting to address today? *
Your answer
**If you are not getting a Microcurrent Treatment, you may skip to "Medications/Sensitivity" below...**
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Have you ever had skin cancer? Please specify when: *
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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: *
Your answer
Do you have high blood pressure? If yes, Please specify: *
Your answer
Are you currently taking any prescription or over the counter medications? If yes, please list all oral medications you are taking. *
Your answer
Do you suffer from Epilepsy or seizures? *
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Have you ever had surgery? If Yes, Please specify.. *
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Have you had Botox or Fillers recently? Please specify date: *
Your answer
Do you have Vericose veins? If Yes, Please specify.. *
Your answer
Do you have any contagious diseases? If Yes, Please specify.. *
Your answer
I Certify that I am not HIV positive, have AIDS or Hepatitis C ~ initial please: *
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Do you have osteoporosis? *
Your answer
Do you have Autoimmune disorder? Is it under control? Please specify: *
Your answer
Have you had Shingles? When? *
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Have you had any broken bones in the past 2 years? *
Your answer
Do you experience back pain? Please specify: *
Your answer
Have you been in an accident or had any injuries in the past 2 years? *
Your answer
Do you have tension or soreness anywhere? Please specify *
Your answer
**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. *
Your answer
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. *
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Name and Date below: *
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