Skincare Intake Form

Phone

This field is for validation purposes and should be left unchanged.

Contact

Name(Required)

First Last

Email(Required)

Phone(Required)

Phone Type

Home

Mobile

Work

Other

It's OK to text me!(Required)

Yes

Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

Occupation

Emergency Contact(Required)

Emergency Contact Phone(Required)

Emergency Contact Relationship

How frequently do you receive skincare services?

First Time

Once a year or less

2-3 times/year

4-6 times/yr

7-10 times/yr

Monthly or more frequent

Medical History

Medical | Procedural History(Required)

Cancer diagnosis

Pregnant or Lactating

Hormone replacement therapy

Diabetes

Epilepsy / Seizure disorder

Blood thinners or clotting disorder

History of cold sores (oral herpes)

Atuoimmune disorder (ex. Lupus, Rheumatoid arthritis, Thyroid disorder

Pacemaker or implanted electronic device

Metal implants

None

When was your last chemical peel?(Required)

When was your last facial?(Required)

This field is hidden when viewing the form

Date of last facial hair removal

This field is hidden when viewing the form

Method of Removal

Chemical Removal

Laser

Shaving

Waxing

Threading

Other

Are you currently or have you been under a physician/dermatologist care within the last year?(Required)

Yes

If yes, when:

Recent cosmetic injectables/dermal fillers? (4-6 weeks)(Required)

Yes

If yes, which ones?

FBotox/Xeomin/Jeuveau

PRP/PRF

Vollure/Voluma/Volbella

Radiesse/Sculptra

Other

This field is hidden when viewing the form

Have you been diagnosed with cancer in the last 5 years?

Yes

List all prescription drugs, shots, or creams you are currently using(Required)

This field is hidden when viewing the form

List all medical conditions you have

This field is hidden when viewing the form

Are you undergoing hormone replacement therapy?

Yes

If yes, specify

Do you have any allergies? Check all that apply(Required)

None

Nuts

Soy

Milk

Latex

Iodine

Shellfish

Lavendula

Aluminum

Fragrance

Metals

Latex

Pollen

Other

This field is hidden when viewing the form

Do you have or are you prone to?

Ingrown Hairs

Rashes/Eczema

Scarring

Athlete’s Foot

Burns/Sunburns

Bruising

Hyper-pigmentation

Open Wounds/Sores

Herpes (Cold Sores)

None

This field is hidden when viewing the form

Have you used any of the following?

Accutane

Retin-A

Alpha-Hydroxy Acid

Glycolic Acid

Resorcino

Scrub /Peel

None

Do you use a Tanning Bed?(Required)

Yes

If yes, when and how often?

Have you had recent natural sun exposure?(Required)

Yes

If yes, when and how often?

This field is hidden when viewing the form

Have you used any other skin thinning medications?

Yes

If yes, which ones?

This field is hidden when viewing the form

Do you use Retinol/vitamin A derivative products?

Yes

If yes, Specify which kind & date of last use

What type of skin do you have?(Required)

Normal

Dry

Oily

Combo Dry

Combo Oily

Acne Prone

Sensitive

What are your concerns today?(Required)

Uneven Skin Tone

Hyperpigmentation

Melasma

Blackheads

Acne

Fine Lines

Wrinkles

Dull/Dry Skin

Rosacea

Excessive Oil

Dry Lips

Dark Circles

Relaxation

Stress Relief

None

This field is hidden when viewing the form

GUESTS WHO ARE PREGNANT OR LACTATING

This field is hidden when viewing the form

Are you pregnant or trying to get pregnant?

Yes

This field is hidden when viewing the form

Are you lactating?

Yes

This field is hidden when viewing the form

Any recent changes to your contraceptive treatment?

Yes

If yes, list name of contraceptive

This field is hidden when viewing the form

Are you taking oral contraceptives?

Yes

If yes, specify:

Are you going through menopause?(Required)

Yes

If yes, list any issues you are having since this hormonal change:

This field is hidden when viewing the form

Yes

GUESTS WITH FACIAL HAIR

What is your current shaving system(Required)

Wet shave

Electric

Disposable razor

Laser Hair Removal

None

Do you experience irritation from shaving?(Required)

Yes

N/A

Do you get ingrown hairs after shaving?(Required)

Yes

N/A

Consent(Required)

I agree to the notice.

My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I consent to photographs being taken to evaluate treatment efficacy and for social media use. No photographs revealing my identity will be used without my written consent. I hold harmless LaVida Massage + Skincare, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen. If I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL.

Signature(Required)

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Number

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

LaVida Massage of Fort Collins

LaVida Massage of Fort Collins