Patient Intake Form Please fill out the form below Fields marked with an asterisk are required. Step 1 of 8 12% Date* Date Format: MM slash DD slash YYYY Patient Name* First Last Address* Street Address Address Line 2 City State ZIP Email* Phone*May we leave a message?*YesNoPreferred method of communication from our office? (please check all that apply)* Text Phone Call Email Date of Birth* Date Format: MM slash DD slash YYYY Age*Sex*MaleFemaleMarital StatusOccupationEmployerEmergency Contact NameRelationshipEmergency PhoneHow did you hear about us?Reason for consultationPlease describe your skin and skin concerns (please check all that apply) Thick Thin Saggy Firm Fine Lines Wrinkled Aging Dry Normal Oily Combination Large Pores Sun Freckles Uneven/Blotchy Active Acne Acne Scars/Scars Blackheads/Whiteheads Cysts Dark Spots/Patches Scaling/Flaking Broken Capillaries Sallow Puffiness Rosacea Dehydrated Eczema or Psoriasis Dark Circles/Eyes OtherAre there any other treatments/conditions you are interested in hearing more about? (please check all that apply) Longer lashes Dark spots/hyperpigmentation Excessive sweating Thinning hair Vaginal rejuvenation Scar treatment Double chin Fine lines and wrinkles Skin laxity Medical grade skin care Acne Hair removal OtherWhat is important to you when deciding on a skin treatment?Untitled Do you have any allergies* Yes No If yes please specifySKIN CAREDo you have any special skin problems pertaining to your face and body?YesNoIf yes please specifyDo you suffer from claustrophobia? Yes No Do you experience irritation from shaving?YesNoDo you experience ingrown hairs?YesNoFor unwanted hair do you Wax Tweeze Electrolysis Describe your current skin care regimen:What brand name(s) to do you use?What spf sunscreen do you use on your face?What spf sunscreen do you use on your body?Please specify if you have had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray tans?Are you using Retin-A, Hydroquinone (bleaching cream), glycolic acid, Accutane or any other medication that could cause sun sensitivity?YesNoIf yes please explain SOCIAL HISTORYDo you follow a restricted diet?YesNoIf yes please explainDo you smoke cigarettes?YesNoIf so how many packs a day, how many years?Do you drink alcohol?YesNoIf so how many drinks per day/weekDo you use drugs?YesNoIf yes please explainDo you have regular sleep patterns?YesNoIf no please explainDo you consume caffeinated products?YesNoIf yes please explain MEDICAL HISTORY Please fill out as completely as you are able. All information will be held in strict confidence. Name of Primary Care ProviderOffice PhoneIllnesses over past 5 yearsChronic or Current ConditionsNeurologic ConditionsYesNoIf yes, please explainCardiovascular ConditionsYesNoIf yes, please explainRespiratory ConditionsYesNoIf yes, please explainEndocrine ConditionsYesNoIf yes, please explainLiver ConditionsYesNoIf yes, please explainKidney ConditionsYesNoIf yes, please explainAutoimmune ConditionsYesNoIf yes, please explainInfectious ConditionsYesNoIf yes, please explainCoagulation ConditionsYesNoIf yes, please explainHereditary ConditionsYesNoIf yes, please explainConnective Tissue DisordersYesNoIf yes, please explainCancersYesNoIf yes, please explainEye ConditionsYesNoIf yes, please explainSkin ConditionsYesNoIf yes, please explainPsychological ConditionsYesNoIf yes, please explainSurgery, Including CosmeticYesNoIf yes, please explainDo you faint easily?YesNoDo you scar easily?YesNoIf yes, please explainDrug TherapyPlease list any prescribed or over the counter oral or topical medications you are currently using, including: allergy medications, acne treatments, Aspirin, Ibuprofen, herbs & vitamins: Pharmacy NamePharmacy PhoneHave you ever seen a dermatologist?YesNoIf yes, please explainDermatologist NameDermatologist PhoneSKIN CARE - have you ever had a chemical peel?YesNoLast treatment date and area treatedSKIN CARE - have you ever had microdermabrasion?YesNoLast treatment date and area treatedHave you ever had any laser or photofacial treatments in the past?YesNoLast treatment date and area treatedDo you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), keloid scars or marks/scars from physical trauma, chicken pox or acne?YesNoIf yes, please describeDo you have any permanent cosmetic tattoos?YesNoLast treatment date and area treatedHave you ever had Botox® or Dysport® injections?YesNoLast treatment date and area treatedHave you had previous dermal filler, Kybella™or Sculptra® injections?YesNoLast treatment date and area treatedFrequent or occasional cold sores to mouth or genitalia?YesNoDo you wear contact lenses?YesNo FOR WOMEN ONLYCould you be pregnant?YesNoAre you breastfeeding?YesNoAre your menstrual cycles normal?YesNoBirth control pills?YesNoDepo-Provera?YesNoDate of last shotMenopausal/peri menopausal hormone replacement therapy?YesNoPeriodic acne flare-ups related to cycle?YesNo WAXING PATIENTS ONLYPlease indicate whether any of the following apply to you: Recent scar tissue, cuts, bruises or other abrasions to area being waxed Skin Diagnosis (Eczema, Psoriasis, Ringworm, Lice etc.) Sunburn or Heat Rash in the past 24 hours Hypersensitive or highly reactive skin Use doctor prescribed acne products or RX prescriptions that cause skin sensitivity in the past 6 months Medical Spa treatments (Chemical peels, Botox, Dermal Fillers, Laser Etc.) Varicose Veins or Capillary damage in the treatment area Hemophilia High/Low Blood Pressure Allergies Pregnant Previous reactions to waxing Do you have any piercings on the area being waxed today?YesNoI understand that waxing can cause irritation, inflammation, and in some cases a rash.YesNoI confirm that the above information is true to the best of my knowledge and belief. I hereby give my consent to proceed with waxing.YesNo Lash Lift Patients Only Previous discomfort, stinging or adverse reactions? Please check all that apply: Skin Disorders Eye Infections Watery Eyes Bell's Palsy Allergies to Latex/Band Aids Are you pregnant or Lactating? Inflammation of the skin Recent Eye Surgery Hay Fever Previous reactions to eye treatments or eye gels? Allergies to glue/bonding agents/ adhesives Are you on the contraceptive pill? Eye Disease Blephartitis Contact Lenses Allergies to acetone Are you taking HRT? Have you had a Lash Lift or Lash Tint before? Yes No Empower MedSpa does offer a sensitivity patch test to be done prior to any Lash Lift service. The sensitivity test would notify my provider of any sensitivity or allergies I would have to the products used in my Lash Lift service. Yes, I would like to have a patch test completed. I understand it could take up to 48 hours before I receive my results. No, I consent to the procedure being carried out without undergoing a sensitivity patch test. Cancellation/No Show Policy* I agree to the Cancellation/No Show Policy below. We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment within 24 hours, you may be preventing another patient from getting a much-needed service. Conversely, the situation may arise where another patient fails to cancel, and we are unable to schedule you for an appointment. If an appointment is not canceled at Empower MedSpa at least 24 hours in advance you will be charged a fifty-dollar ($50) fee.Your Name*Entering your name here acts as your signatureDate of Submission* Date Format: MM slash DD slash YYYY UntitledUntitled