Client Intake and Med HX

Name

First NameLast Name

Date of Birth

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

How did you hear about Lively Aesthetics?

Are you currently under the care of a physician for any reason?

If yes, for what?

Please select all that apply to you

Please explain above problems or list any other significant issues

Are you currently taking any medications?

If so, please list them

Are you pregnant?

Are you currently taking birth control?

If you are taking birth control, what type?

Are you presently using, or have used in the last 6 months, any of the following?

If "yes", when and for how long?

Please list any allergies you have

Please list your current skincare routine and what products you use

What are your main concerns with your skin?

I understand that the services offered by Lively Aesthetics are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving appropriate services and is completely confidential.

Client Signature

Consent to treatment of a minor
By signature below, I hereby authorize esthetician name to perform esthetic services to my child or dependent, as they deem necessary.
Signature

Form

Client Intake Form and Medical History