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Microsoft word - clientintakeskin.doc

WELCOME TO TAOMASSAGE
SKINCARE
Client Intake and Informed Consent Sheet

PLEASE PRINT

Whom may we thank for referring you?
(You will be added to the TaoMassage business list and receive periodic annoucement, promotions, etc) ❏ DO NOT ADD ME TO EMAIL LIST 1. What type of massage do you prefer? ❏ soft ❏ medium ❏ firm 2. FEMALES ONLY: Are you pregnant? 3. Are you wearing contact lenses today? ❏ Yes 4. ALLERGIES and REACTIONS to any of the following: ❏ cosmetics ❏ skin care product ❏ medicine ❏ iodine ❏ pollen ❏ food ❏ shellfish ❏ hydroxy acids(i.e. glycolic, salicylic), ❏ animals ❏ fragrance ❏ sunscreens ❏ fruit ❏ essential oils ❏ other/specify 4. Have you ever been under a dermatologist’s care? ❏ Yes ❏ No 5. Have you ever had a skin treatment before? ❏ Yes ❏ No If YES: WHEN was your last facial? ❏ within the past 3-6mos What did you dislike about the expereince? ❏ normal ❏ oily ❏ water dry ❏ oil dry ❏ acne prone ❏ combination (oily in T-Zone) 2. What skin care products are you currently using? ❏ soap ❏ cleanser ❏ toner/astringent ❏ moisturizer ❏ masque ❏ exfoliant ❏ eye care ❏ sunscreen ❏others TaoMassage LLC 2116 Sunset Avenue, Ocean, NJ 07712 3. YOUR SKIN CONCERNS: Do you have any special areas of concern pertaining to your face? ❏ redness/sensitivity or uneven complexion ❏ would like smoother, more refined texture SECTION 4: EXFOLIATION AND BLEACHING HISTORY 4. Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments? 5. Do you use Accutane, Retin A, Renova, or Adapalene? ❏ yes ❏ no, ❏ in last 3 months? ❏ yes ❏ no 6. Do you use an acne medication? ❏ yes ❏no, ❏ in last 6 months? ❏ yes ❏ no 7. Are you currently using any products that contain the following ingredients? ❏ Glycolic Acid ❏ Lactic Acid ❏ Salicylic Acid ❏ exfoliating scrubs ❏ Hydroxy acid products ❏ Vitamin A derivatives (i.e. Retinol) ❏ Sulfur Cortisone ❏ Cleocin-T 8. Have you ever used a bleach (Hydroquinone) or fade cream (Kojic Acid) or and over-the-counter product? ❏ Hydroquinone ❏ Kojic Acid ❏ Over-the-counter product name: 9. Did you experience an allergic reaction to the bleach or fade cream such as: swelling, itching or fine 10. Are you using any topical medications that cause you to peel? ❏ yes ❏ no
Please read the following statement carefully, then sign below.
 I understand fully that services provided at TaoMassage are not a substitutes for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment I may have. I also understand that failure on my part to disclose informaiton could result in injury and/or illness and I hereby release TaoMassage and its agents from any claims resulting in such. I have stated all known medical conditions and take it upon myself to keep my service provider therapist updated on my physical health.  I understand thay anu information given is stricly confidential and will be used for no other purpose tha to assit your service provider in provinding suitable treatment which would take into consideration my specific requirements.  I understand that any illicit or sexually aggressive remarks, advances or gestures made by me will result in the immediate termination of the session,and I will be liable for payment of the scheduled appointment.
I have carefully read and understand all of the above and I have answered
all questions fully and accurately.

TaoMassage LLC 2116 Sunset Avenue, Ocean, NJ 07712

Source: http://www.taomassage.com/ClientIntakeSKIN.pdf

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