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If Yes Please Indicate Changes On Form

This document contains a client intake form for skincare treatments. It collects information such as name, contact details, medical history, previous treatments, skin conditions, and current skincare routine. The client's top 3 concerns are noted. A treatment consent section is included which the client initials to acknowledge risks, side effects, and pre-treatment recommendations. The specific treatment receiving and technician notes are documented.

Uploaded by

Gaia Wellness Company
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
151 views

If Yes Please Indicate Changes On Form

This document contains a client intake form for skincare treatments. It collects information such as name, contact details, medical history, previous treatments, skin conditions, and current skincare routine. The client's top 3 concerns are noted. A treatment consent section is included which the client initials to acknowledge risks, side effects, and pre-treatment recommendations. The specific treatment receiving and technician notes are documented.

Uploaded by

Gaia Wellness Company
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Client Information

Date______________

If you previously filled out this form: Any changes since last visit? £ No £ Yes If yes please indicate changes on form.

Name _______________________________________________Gender: M F Age ______ DOB _______________


Address ______________________________________________City________________State_____ Zip ________
Preferred Contact Number _________________________________ Email ______________________________________
May we leave a message if we do not reach you personally? Yes No

What are your top 3 concerns at this time?


1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________

Medical History: Pregnant? Yes No Maybe N/A Breastfeeding? Yes No N/A


Do you smoke? Yes No
Health Conditions: _____________________________________________________________________
Past Surgeries: ____________________________________________________________________
Have you ever been diagnosed with Cancer? £ No £ Yes (date of last treatment)___________
Current Medications: _________________________________________________________
Prescription Topicals: ______________________________________________________________
Allergies (include aspirin & iodine): __________________________________________________

Previous Treatments:
Facials Yes No Last treatment:____________Any complications?_________________________________
Microdermabrasion Yes No Last treatment:____________Any complications?_________________________________
Chemical Peels Yes No Last treatment:____________Any complications?_________________________________
Waxing Yes No Last treatment:____________Any complications?_________________________________
Tanning Yes No Last treatment:____________Any complications?_________________________________
Laser Therapy Yes No Last treatment:____________Any complications?_________________________________
Massage Yes No Last treatment:____________Any complications?_________________________________

Skin Conditions: (please circle the items below that pertain to you)
Skin Infection Herpes (cold sores) Keloids/Excessive Scarring Sun Sensitivity
Skin Cancer Poor Healing Tattoos/Permanent Makeup Easy Bruising
Eczema Psoriasis Lymph Nodes Removed Diabetes

Skincare: What type of skin do you feel you have? Dry Oily Normal Combination
What is your skin routine? (Indicate any cleansers, toners, serums, moisturizers, masques, etc.)
1.________________________________________ 4._____________________________________________
2._______________________________________ 5._____________________________________________
3._______________________________________ 6._____________________________________________
Osmosis Treatment Consent Date______________

Client Name ________________________________________________________

Please Initial:
________ I agree that the nature and purpose of the treatment has been explained to me and any questions
I have regarding the treatment have been explained to my satisfaction.

________ I understand that with any treatment certain risks are involved and that any complications from
known or unknown causes could occur.

________ I understand that possible side effects include, but are not limited to: mild to moderate redness,
mild to moderate peeling or flaking, stinging, dry skin, tenderness, pimples, cold sores or allergic
reactions. Most side effects are temporary and will dissipate within 3-7 days.

________ I do not have active cold sores.

________ I will call to inform my skincare professional of any complications or concerns I may have as soon
as they occur.

________ I understand that it is recommended prior to having a facial infusion to not have used Retin A for
72 hours, Accutane in 6 months or have waxed 24 hours prior to receiving treatment.

__________________________________________________________________________________________________________________
CLIENT SIGNATURE PRINT NAME DATE

Technician Notes:
Treatment Receiving Today (check one):
£ Medi-Facial £ Holistic Calming Facial
__________________________________________________________________________________________________________________
£ Facial Infusion £ Holistic Stimulating Facial
__________________________________________________________________________________________________________________
£ Medi-Infusion £ RevitaPen Facial
__________________________________________________________________________________________________________________

Notes:

I have reviewed the treatment and post care instructions to the client stated above and answered any questions.

________________________________________________________________________________________________________________
TECHNICIAN SIGNATURE DATE

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