Cosmetic Intake Form

First Name

Middle Name

Last Name

DOB

Mailing Address:Street

Apt #

City

State

Zip

Home Phone

Cell Phone

Work Phone

Gender

Male Female

Marital Status

S M D W

Ethnicity

White

Hispanic

Asian

Black/African American

American Indian or Alaska Native

Hawaiian or Pacific Islander

Other

If other, please specify.

Language

English

Spanish

Other

If other, please specify.

**Would you be interested in receiving emails on any upcoming cosmetic promotions and specials?

If yes, please provide us with your E-mail address

We offer many aesthetic services, products, and procedures. If you would like more information, please check the box of all that you are interested in:

If other, please specify.

What cosmetic treatments and procedures, if any, have you had in the past?

If you have previously had any cosmetic treatments or procedures, were you pleased with the outcome?

Yes No

If no, what was the procedure and in what way were you dissatisfied?

Do you have permanent make-up or tattoos anywhere?

Yes No

Do you sunbathe, or go to tanning salons?

Yes No

Do you use chemical sunless tanning?

Yes No

Which of the following best describes your skin type and natural hair color?

Medical History

Smoking

HIV / Hepatitis

Pregnant

Cold Sores / Fever Blisters

Waxing / electrolysis

Bleed Easily

Problems Healing

Keloids / Raised Scars

Accutane

Other

Reactions to skin care products

Plastic surgery (list)

Skin cancer (list)

Medications

Are you pregnant, or trying to become pregnant?

Yes No

Are you taking any blood thinners?

Yes No

If yes, please list

Please check the box if you have ever been diagnosed with the following:

Hepatitis A-B-C

HIV/AIDS

Cold Sores/Shingles

Anaphylaxis

Sun Sensitivity Disorders

Actinic Keratosis

Keloid Scars

Pigmentary Disorders

Other illnesses or medical conditions?

Autoimmune and neurologic diseases: (please check all that apply)

Myasthenia Gravis

Eaton-Lambert Disease

Multiple Sclerosis

Lupus

Scleroderma

Other

If other, please specify.

Are you allergic to any of the following products/ medications?

If yes, please describe the reaction.

Please list any allergies not listed above.

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