Client Intake and Consent for Skincare Form 0 Client Intake and Consent for Skincare Arch & Crown Aesthetics 886 Pompton Ave, Suite A1Cedar Grove NJ, 07009 Arch & Crown Aesthetics 110 Fairview Ave. Verona, NJ 07044 Info@archandcrownaesthetics.com Client Info: Name : Date of Birth : Email : Ethnic Background (Please include all nationalities): Address: Apt. #: Home Phone: City: State: Zip Code: Cell Phone: Occupation: If we call you at home, do you want confidentiality? YesNo May we call you at work? YesNo If yes, my work number is : Emergency Contact Information: Name: Phone: Relationship: Who may we thank for referring you? List all medications you are presently taking Name of Drug , mg or mcg , Amount/Day , Why it was prescribed to you? (One data per line) List all medications you took in the last six months that you are no longer taking Name of Drug , mg or mcg , Amount/Day , Why it was prescribed to you? (One data per line) GENERAL MEDICAL DO YOU HAVE (CHECK ALL THAT APPLY)Fever Blisters/Cold Sores (Ever, even one time)Glaucoma or other eye disease/disorderGrave’s DiseaseHeart DiseaseShingles History/Recent Shingles ShotMitral Valve ProlapseValve ImplantsPacemakerStentsDiabetes requiring insulinProblems with healingKeloidsSeizuresDermatological DisorderHemophilia or Clotting DisorderAutoimmune DisorderPre-existing nerve damageTattoosTrichotillomania (pulling of hair, brows, lashes)Alopecia Totalis or AreataAllergiesN/A If Checked Dermatological Disorder if So What : Active or in Flare-ups? : if Checked Tattoos, Colors you are sun sensitive to: if Checked Allergies, list: ARE YOU? (CHECK ALL THAT APPLY)PregnantPlanning cosmetic surgeryCurrently under the care of a physicianN/A If Planing cosmetic surgery, what & when? if Currently under the care of a physician , Describe DO YOU PRACTICE OUTDOOR ACTIVITIES?TennisSwimmingGolfSkiingGardeningWalkingBoatingOtherN/A If Checked Other DO YOU USE (CHECK ALL THAT APPLY)Accutane (currently or within the past year)Antibiotics prior to dental proceduresSteroidsRetin-A, Glycolic Acid, Vitamin C or other ExfoliantsTanning BedsEyebrow TintingEyelash TintingLatisseBotoxChemical PeelsChemotherapy or Prophylactic dose of ChemotherapyBlood ThinnersN/A If Checked Botox, When If Checked Chemical Peels, When HAVE YOU HAD (CHECK ALL THAT APPLY)Fever Blisters/Cold Sores (Ever, even one time)Eye Infections (Are you prone to them)Vision Correction Procedure (Lasik, RK) within the past 3 monthsHeart AttackJoint Replacement, Organ TransplantEye TraumaSeizuresFainting SpellsHepatitisHepatitis TestFat Transfer InjectionsGore-Tex ImplantsAesthetic or Cosmetic ProceduresLaser TreatmentsN/A If Checked Heart Attack, When? If Checked Hepatitis, What type? If Checked Hepatitis Test, When? If Checked Fat Transfer Injections, where? If Checked Gore-Tex Implants, where? If Checked Aesthetic or Cosmetic Procedures, where? If Checked Laser Treatments, What type & why? Physician’s Name : Address : Phone : Specialty :
