Repeat Skincare Intake Form ContactName(Required) First Last Email(Required) Phone(Required)HistoryWhen was your last chemical peel? When was your last facial? Date of last facial hair removal Method of Removal Chemical Removal Laser Shaving Waxing Threading Other List any changes to your medical history since your last appointment:Do you have recent cosmetic injectables/dermal fillers? Yes No If yes, which ones? FBotox/Xeomin/Jeuveau PRP/PRF Vollure/Voluma/Volbella Radiesse/Sculptra Other Date & placement of most recent injection CONCERNSWhat are your concerns today? Uneven Skin Tone Hyperpigmentation Melasma Blackheads Acne Fine Lines Wrinkles Dull/Dry Skin Rosacea Excessive Oil Dry Lips Dark Circles Relaxation Stress Relief SKINCARE PRODUCTS YOU CURRENTLY USE DAILY/WEEKLYCleanser(s) Serums Toner Eye Serum/Cream Exfoliant Moisturizer SPF Other DISCLAIMER(Required) I agreeI understand the treatment(s) I am about to receive is provided by a licensed Esthetician who has undergone all the current state, county, city, and educational requirements necessary to perform these treatments. If I notice discomfort, pain, etc., I will notify my Esthetician immediately. I understand that the application of glycolic acid can cause temporary redness, peeling and mild discomfort and I need to limit sun exposure and use broad spectrum sunscreen during treatment. I also understand my treatments are not to take the place of a doctor’s examination, diagnosis, prescription, or treatment of a physical or mental illness or condition I knowingly or unknowingly currently have. I have to the best of my ability listed all known conditions, injuries, treatments, medications, past or present and hold LaVida Massage and its employees harmless for contraindications or injuries, whether physical or mental, by me not sharing my medical history. I agree to keep any Esthetician affiliated with LaVida Massage up to date on my health.Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
