Cause+Medic Spa Skin Care Intake Form
Email address *
First Name *
Last Name *
Today's Date *
Email *
Phone *
Address *
City, State Zip *
Date of Birth *
Emergency Contact Name *
Emergency Contact Phone *
How did you hear about us? *
Have you ever received professional skin care/esthetics treatments? *
If yes, what types?
Have you been under the care of any physician, dermatologist, or other medical professional within the past year? If so, please explain.
Please list any medications, supplements, or herbal/homeopathic remedies you currently take. *
Are you using any topical medication or exfoliating acids like salicylic or glycolic? *
If yes, please explain.
Have you ever had an adverse reaction to a cosmetic product? *
If yes, please explain.
What are you currently using to cleanse and moisturize your face?
Do you currently use any special treatments? (eye, scrubs, masks, etc.)
How would you rate the overall quality of your skin? *
What improvements would you like to see to your skin?
When you got out in the sun, to what level do you experience sunburn? *
How many glasses/cups of water do you drink daily?
On a scale of 1-10, how would you rate your current stress level? *
Have you ever been treated for: (Select all that apply) *
Do you wear contact lenses? *
If so, are you wearing them now?
Clear selection
If you wear a hormone or nicotine patch, please indicate which kind and where you wear it:
Are you bothered by scents, oils or lotions? If yes, please explain. *
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or any VitaminA/Retinol derivative? *
If yes, have you used these products within the last 3 months?
Clear selection
Have you ever used an acne medication? If yes, when and which one? *
Have you ever had an allergic reaction to food, sunscreens, or AHAs? If yes, please explain: *
I certify that the above information is correct to the best of my knowledge. In accordance with the law, Esthetics/Skin CareTherapy cannot cure, treat, prevent or diagnose any condition. These treatments are used as regimens for improving skin appearance and wellness. Information exchanged during any session should be given at my own discretion.Because certain esthetics treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the skin care therapist updated as to any changes in my health prior to any future sessions and understand that there shall be no liability on the therapist’s part nor on the part of Integrative Life Solutions, Inc. and its affiliates should I fail to do so.The therapist reserves the right to refuse service to anyone for any reason. I fully understand that the therapist performs her services within the parameters of esthetics, using skin care treatments and therapies. I fully understand that the esthetics therapist is not an allopathic doctor, dermatologist, or psychiatrist and does not portray himself/herself to be.If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the products and/or techniques may be adjusted to my level of comfort. By signing below I acknowledge that I have read and understand all parts of this consent/intake form, and that I have had the opportunity to ask any questions with regard to any services or therapies offered. All client information is confidential. Digital Signature (full name): *
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