Health Information/Intake

Health Information/Intake

Practitioner Name: Valerie Kemplin, 1553800

(Client Contact Information)

Client Name: ______Date:______

Date of Birth: ______Gender: ______

Address: ______

Phone: ______Email: ______

Referred by: ______

Health History

Within the last year, have you been under a dermatologist care? Yes No

If yes, please specify:______

List the medications you currently take:______

Do you wear contact lenses? Yes No

Do you have any metal implants, a pace maker or body piercings? Yes No

Do you have any allergies (latex, shellfish, nickel, scents, nuts)? Yes No

If yes, please specify: ______

Do you sunbathe or use tanning beds? Yes No

Have you ever experienced claustrophobia? Yes No

(For waxing & body treatments) Do you have varicose veins, edema or diabetes? Yes No

Your Skin

What are your specific concerns or challenges with your skin? ______

What type of products are you currently using? (Soap, exfoliator, moisturizer, sun screen) ______

Have you had any skin treatments within the last month? Yes No

Have you waxed with the last 48 hours? Yes No

Have you used Retin-A, Accutane or any other prescription medications within the last 3 months? Yes No

Females Only

Are you taking an oral contraceptive? (This may affect your results) Yes No

Are you pregnant? Yes No

Males Only

Do you have shaving challenges?(Razor burn, etc) Yes No

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the treatment may be adjusted to my level of comfort. I further understand that esthetic care should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. . I understand that esthetic practitioners are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because esthetic care 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. It is my choice to receive this treatment & have provided accurate information to the best of my knowledge. I understand that there is a possibility that I may have an allergic reaction or incur other adverse effects of the treatments. I have voluntarily assumed the risk of proceeding with this treatment. Understanding all of this, I give my consent to receive care.

Client Signature: ______

Date: ______

Parent or Guardian Signature (in case of a minor): ______