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SKIN HEALTH INTAKE FORM
SKINCARE ELEMENTS
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Full Name
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Your answer
Email
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Your answer
Phone Number
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Your answer
Address
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Your answer
Date of Birth
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MM
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DD
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YYYY
How did you hear about Skincare Elements?
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Your answer
Please describe a brief history of your skin.
Share any sensitivities or aversions.
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Your answer
What is your current skin care routine?
What products do you use?
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Your answer
Where would you like to see changes in your skin?
(if any)
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Your answer
List any known allergies.
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Your answer
Have you had any of the following done in the last 4 months? (
Select all that apply)
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Chemical Peels
Botox (if yes, sessions cannot begin until 6 months after)
Fillers (if yes, sessions cannot begin until 6 months after)
Any other facial injections
LED light therapy
Microneedling
Laser treatments
IPL photofacial
eMatrix
Sublime
Vein Removal
Permanent Tattoo/Removal
Are you currently on Retinol/Retinoids products?
I have not had any of the above within the last 4 months.
Required
LED Light Therapy Questions
Check any of the following that applies to you:
Pregnant or breastfeeding
Epilepsy or a history of seizure
Photosensitive disorder
Light induced migraines
Currently taking St John’s Wort or other herbal remedies
Cortisone or steroid injections
Photosensitive drugs (ex. isotretinoin, lithium)
Skin cancer
Antibiotics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Diuretics
Retinoids
HMG-CoA reductase inhibitors
Epidermal growth factor receptor inhibitors (treatment for lung cancer)
Antifungals
Anti Arrythmic drugs
Anti-arthritic
Anti-Cancer drugs
None of the above
How would you describe your current diet, digestion/gut microbiome health?
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I feel good/balanced.
I feel imbalanced.
This has been an issue in the past.
I am currently working with someone to address it.
Other:
Required
How would you describe your current stress level?
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Low
Medium
Struggling to manage
I am currently working with someone to address it.
Other:
Required
Is there anything else you'd like to share to better help us work together?
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Your answer
Policies, Terms + Conditions
Please update Skincare Elements about any changes in your skin condition, skincare routine, or health status before your next appointment.
To secure your appointments, we require a credit card on file.
The cancellation policy requires a notice of 48 hours before your scheduled appointment. If you cancel within less than 48 hours, you will be charged the full amount.
Failure to show up for appointments or repeated cancellations/reschedules may result in inability to rebook in the future.
Client Acceptance
of Policies, Terms + Conditions
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I understand and accept the polices, terms, and conditions explained above.
Required
Virtual Signature
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Your answer
Date
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