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We’re so excited to care for you.

This intake form is required prior to receiving any facial or aesthetic treatments. It ensures we understand your unique skin concerns, medical history, and treatment goals—so we can safely deliver the best possible results.

This form includes:

  • Personal and contact details
  • Skin type and current skincare routine
  • Medical history and allergies
  • Aesthetic concerns and treatment goals
  • Consent to treatment and HIPAA privacy acknowledgement

All information is kept strictly confidential. If you have any questions, please don’t hesitate to ask—we’re here to help!

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Patient Medical History
*Drug Allergies *
List all medication & supplements currently taking
*Do you have any infections or active flu-like illnesses?
Pregnant or Breastfeeding*
No
Yes

Click to customize text

Have you ever had:
Any botulinum treatments such as Botox, Dysport, Jeuveau, Xeomin, or Daxxify? If so, have you had any botulinum to the treatment area you are planning on receiving today within the last 90 days?*
No
Yes
Have you had dermal fillers or permanent makeup in the area being treated today within the last 90 days?*
No
Yes
Bleeding or Clotting Disorder (Including any history of blood clots, DVT, pulmonary embolism, stroke, severe anemia, thrombocytopenia, hemophilia, and Von Willebrand)*
No
Yes
Cardiovascular Disease (Including any cardiac disorders, coronary artery disease, blocked arteries, high blood pressure). If yes, provide extensive details.*
No
Yes
Chest Pain*
No
Yes
Seizures? If yes, are your seizures controlled? Are you on medications for your seizures? When was your last seizure? Do you have seizures that are triggered by light?*
No
Yes
Any steroid use currently (such as prednisone) or within the last 4 weeks?*
No
Yes
Pulmonary Embolism*
No
Yes
Hypertension*
No
Yes
Neurologic disorder (Including Migraines, Myasthenia gravis, Lambert-Eaton Syndrome, and ALS). If any, specify which one and provide details.*
No
Yes
Bleeding disorder? If yes, please specify which bleeding disorder and if so, are you on medication (please specify medication)*
No
Yes
If Yes to Bleeding Order, specify what bleeding order and medication
Blockage of Arteries, Swelling, Edema, or Stroke*
No
Yes
Shortness of Breath*
No
Yes
Thyroid*
No
Yes
Hepatitis*
No
Yes
HIV/AIDS*
No
Yes
Immune disorders? If yes, specify which immune disorder and whether you are on an immunomodulator for reported condition.*
No
Yes
If yes, specify which immune disorder and whether you are on an immunomodulator for reported condition.
Anaphylactic reaction to anything (i.e. bee sting, wasp sting, specific food, etc.)*
No
Yes
Oral Herpes*
No
Yes
Shingles*
No
Yes
History of keloid scarring or hypertrophic scar formation*
No
Yes
Historical reaction to aesthetic services (lasers, injections, peels etc.)*
No
Yes
History of facial trauma/facial plastic surgery, including autologous fat transfers, facial implants or collagen implantation*
No
Yes
History of (or active) cancer in the treatment area? If so, please specify when, what type of cancer and what kind of treatment you received.*
No
Yes
If so, please specify when, what type of cancer and what kind of treatment you received.
Recent dental cleaning in last 2 weeks or plans for dental cleaning/procedure in next 4 weeks?*
No
Yes
Recent vaccines (last 4 weeks)*
No
Yes
Bells Palsy? If yes, is it currently active? When was the last episode? Do you have any residual symptoms?*
No
Yes
If yes, is it currently active? When was the last episode? Do you have any residual symptoms?
Taken Accutane (or products containing isotretinoin) in the last 6 months*
No
Yes
Autoimmune disorder (Including lupus, thyroid disorders, and scleroderma)*
No
Yes
Connective Tissue Disorder (Including Ehlers-Danlos syndrome), Neurologic/Neuromuscular Disorder (Including Migraines, Myasthenia Gravis, Lambert-Eaton, and ALS), or Musculoskeletal Disorder (Including Rheumatoid arthritis, and abnormal swelling or edema)*
No
Yes
History of Abdominal Hernia*
No
Yes
Wound Healing Disorder*
No
Yes
History of eye disorders (Including glaucoma, inflammatory eye conditions, double vision, macular edema or degeneration)*
No
Yes
Photosensitivity or any condition that increases sensitivity to light (Including lupus and porphyria)*
No
Yes
Complications or adverse reactions after receiving any medical, aesthetic, or med spa treatment in the past?*
No
Yes
If yes to the above, please explain
Any allergy to aesthetic products (Boxtox, Dysport, Xeomin, Sculptra, Dermal fillers, Kybella, PDA threads, Ascelera, Varithena, sclerotherapy, etc.)*
No
Yes
Allergies to medications, foods, latex, or other substances, including a milk protein allergy, cobalt allergy, or allergy to soy products*
No
Yes
Do you have any of the following?
Hyperpigmentation
Lack of sensitivity to heat
Muscle weakness or muscle atrophy
Active Acne
Skin conditions (including infection, eczema, rosacea, and psoriasis)
Wounds (including injuries, rashes, cuts, and scars)
None
Do you have any implanted medical devices or a history of surgeries?
Copper IUD
Defibrillator, Pacemaker, Neurostimulator
Medication pump (Including insulin and pain medication)
Metal (Including braces, orthopedic plates, and/or screws)
Silicone implants (list implants in the text box below)
Past surgeries (List the surgery and date in text box)
List any surgeries or implants if selected "Yes" above
How does your skin respond to sun exposure without sunscreen? Choose the option that best describes your skin. *
Type 1: Burns without tanning. Very pale white skin, often with green or blue eyes and fair or red hair
Type 2: Burns and does not tan easily. White skin, often with blue eyes
Type 3: Burns first then tans. Fair skin with brown eyes and brown hair
Type 4: Burns a little and tans easily. Light brown skin, dark eyes, and dark hair
Type 5: Easily tans to a darker color and rarely burns. Brown skin, dark eyes, and dark hair
Type 6: Never burns but tans darker. Dark brown or black skin, dark eyes, and dark hair
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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