Intake Form Skincare & Waxing Information/Consent Form Name * First Name Last Name Email * Phone * (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Birthday * MM DD YYYY Do you have special skin concerns? * What would you like to achieve from your skincare treatment today? * Do you use a prescription Retin-A? * Yes No Do you use an over the counter Retin-A, Renova, or Retinol/VitaminA derivative products? * Are you currently taking Accutane or have you taken it in the past? * Have you used other medication for acne or rosacea? * Please list any other medications and or supplements and vitamins you are taking: * Are you exposed to the sun on a daily basis or do you use a tanning bed? * Have you ever had a skin treatment before? * Yes No Have you used any alpha-hydroxy acid or glycolic acid products in the last 48 hours? * Yes No Do you consume nicotine? * Yes No Have you ever had an allergic reaction to any of the following? * Cosmetics Sunscreen Pollen Shellfish Medications Food AHA’s Fragrance Are you taking hormonal contraceptives? * Yes No Are you pregnant? * Yes No Are you trying to become pregnant? * Yes No Are you nursing? * Yes No Have you ever had? * Botox Restylane Other Injections No Injections If so how long ago? * Are you experiencing any menopause problems? * Are you undergoing any hormone replacement therapy or cancer treatments? * How often is realistic for you to come in for a service? Twice a Month Once a Month Every Other Month Seasonally I’m Not Sure Yet PLEASE SIGN: I understand this consent form and have answered each question truthfully. I understand that withholding information from my skin care therapist may result in contraindications or skin irritation from treatments received. * PLEASE SIGN: The Skincare and waxing treatments I receive at Elderflower Esthetics are voluntary and I release Elderflower Esthetics from all liability and assume full responsibility therefore. * Thank you!
