Please print and fill out the form below to the best of your knowledge prior to your appointment at Serene Solutions (Located at “Flote” 845 Lafayette Road, Hampton NH) - If you prefer to cut, paste and email - Please send to Julie@SereneSolutionsNH.com - Thank You!
CONFIDENTIAL INTAKE FORM – SKIN CARE/ESTHETICS
Name _________________________________________Date ________________
Date of Birth _______________Home/Cell Phone __________________________
Address:___________________________________________________________
Email Address _________________________________________________________________
check if you do not want to receive Specials Offers, Event information or Birthday Coupons ____
Emergency Contact _______________________________ Phone _________________________
1. How did you hear about us? ___Advertisement? ___Family/Friend? ___Website? ___Internet Search?
Other source ______________________________________________________________________________
2. Have you ever received professional skin care/esthetics treatments? Yes / No
3. Have you been under the care of any physician, dermatologist, or other medical professional within the past year? If so, please explain:________________________________________________________________________
4. List any medications, supplements, or herbal/homeopathic remedies you currently take: ______________________________________________________________________________
5. Are you using any topical medication or exfoliating acids like salicylic or glycolic? (Yes / No) If yes, explain: ______________________________________________________________________________
6. Have you ever had an adverse reaction to a cosmetic product? (Yes / No) If yes, explain: ______________________________________________________________________________
7. What are you currently using to cleanse and moisturize your face? ______________________________________________________________________________
8. Do you currently use any special treatments? (eye , scrubs, masks, etc.) ______________________________________________________________________________
9. How would you rate the overall quality of your skin? POOR FAIR GOOD VERY GOOD EXCELLENT
10. What improvements would you like to see to your skin?_______________________________
11. Would you describe your skin as (circle all that apply) :
DRY OILY ACNEIC SENSITIVE MATURE COMBINATION
Other Conditions you may want to report_____________________________________________
12. How many glasses/cups of water do you drink daily? _________________________________
13. On a scale of 1-10, how would you rate your current stress level? (low) 1 2 3 4 5 6 7 8 9 10 (HIGH)
14. Have you ever been treated for: (Circle all that apply)
Acne Depression Skin Disease High Blood Pressure Frequent Cold Sores Diabetes Skin Cancer
Hormone Imbalance Hepatitis Herpes Skin Lesions Keloid Scaring Metal Bone Pins/Plates
15. Do you wear contact lenses? (Yes / No) and Are you wearing them now? (Yes / No)
16. Are you bothered by scents, oils or lotions? (Yes / No) If yes, explain:_______________________
________________________________________________________________________________
17. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or any
Vitamin A/Retinol derivative? Yes / No If yes, have you used these products within the last 3 months? Yes / No
18. Have you ever used an acne medication? If yes, when and which one?_____________________
19. Have you ever had an allergic reaction to food, sunscreens, or AHAs? Yes / No If yes, please explain: ________________________________________________________________________________
20. Were you hoping to add any other services today? WAXING HAND or FOOT TREATMENT REIKI SESSION
________________________________________________________________________________
Skin Care Consent Form
I certify that the above information is correct to the best of my knowledge. In accordance with the law, Esthetics/Skin Care Therapy 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 Serene 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.
Client Name Printed _________________________________________
Client Signature_____________________________________________ Date____________________