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TAMA Facial Therapies
Non-Chemical Peels
Skincare Treatments
Hair Removal
Home
About
Services
TAMA Facial Therapies
Non-Chemical Peels
Skincare Treatments
Hair Removal
Products
Contact
Therapeutic Skin Care
Book Now
Tender Touch Therapeutic Skincare
Client Intake
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
(###)
###
####
Referred by:
Occupation
*
MEDICAL
Do you have any health problems we need to be aware of or under a Dr.'s care?
*
Yes
No
If yes, please explain:
Do you have any allergies?
*
Yes
No
If yes, please explain:
Have you had any recent surgery, cosmetic or medical?
*
Yes
No
If yes, please explain:
Have implants?
*
Yes
No
If yes, please explain:
Are you taking any medications (prescription/OTC)?
*
Yes
No
If yes, please list:
Do you smoke?
*
Yes
No
Please check any below that you are currently taking or that you've taken in the past 12 months:
*
DIFFERIN
TAZARAC
RETIN A
RENOVA
ACCUTANE
ALPHAHYDROXY ACIDS
TOPICAL ANTIBIOTICS
NONE OF THE ABOVE
Please check if you have/had any of the following:
*
Acne
Cancer
Circulatory/Lymphatic Issues
Diabetes
Eczema/Dermatitis
High Blood Pressure
Hysterectomy
Menopause/Irregular Periods
Metal Pins
Pacemaker
Poor Sleep Patterns
Pregnant
Rosacea
Smoker
Stress
Stroke
If you have/had cancer, please explain:
If you have/had stress, please rate:
Low -1
2
3
4
5 - High
SUN & GENETICS
Can you tan?
*
Yes
No
Have you ever sunburned?
*
Yes
No
Ever used a tanning bed?
*
Yes
No
Skin Conditions - Please check any that pertain to you:
*
Skin Infection
Herpes (Cold Sore)
Keloids/Excessive Scarring
Sun Sensitivity
Skin Cancer
Poor Healing
Tattoos/Permanent Makeup
Easy Burning
Eczema
Psoriasis
Lymph Nodes Removed
Diabetes
NUTRITION
Time of main meal of the day?
*
Fat free/low fat diet?
*
Yes
No
What type and quantity of fluid do you consume daily?
*
What supplements do you take?
*
SKINCARE
Have you ever had a professional skincare treatment?
*
Yes
No
If yes, what kind?
Any complications?
Have you had a "peel" of any kind (enzyme, AHA, BHA, TCA, Jessner, medical-grade) in the past 12 months?
*
Yes
No
Have you ever had an adverse reaction to a skincare treatment or cosmetic/skincare product? If yes, please describe:
Which skincare products and brands are you currently using?
Cleanser
*
Exfoliator
*
Toner
*
Serum
*
Moisturizer
*
Sunscreen/SPF
*
Mask
*
Eye Cream
*
Night Cream
*
What are your top 3 specific skin concerns or challenges?
*
What do you consider your skin type?
*
Aging
Dry
Oily
Combo
Sensitive
Normal
What results would you like to see from today's treatment?
*
Are you open to using Osmosis recommended product line?
*
Yes
No
I have read the Tender Touch Skincare Policies and understand that if I do not show up for my appointment and fail to call to cancel 24 hours in advance, a fee of $75.00 will incur on my credit card.
*
I certify that all of the above information is true to the best of my knowledge. I understand that the services received here are not a substitute for medical care and any information given by the Esthetician is for education purposes only.
*
Signature
*
First Name
Last Name
Thank you!
