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Needling/Collagen Induction Therapy Intake
Name
Address
Date of Birth
City , State & Zip
Home/Cell Phone
Work
Email
Preferred Contact:Cell
Phone
Emergency contact name
Relationship to you:
Are you over the age of 18 years?
Yes
No
SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):
Very fair skin; blonde or red hair; light-colored eyes; freckles common
Fair skinned; light hair. light eyes
Very common skin type; fair; eye and hair color vary
Mediterranean Caucasian skin; medium to heavy pigmentation
Mideastern skin; rarely sun sensitive
Black skin; rarely sun sensitive
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?
Yes
No
Please list the products you use regularly: Facial Cleanser, Moisturizer, Toner, Serum , Scrubs, Sunscreen, Retinal, Glycolic Acid, Enzymes, Peptides or Growth Factors
Have you had needling or collagen induction therapy in the past?
Yes
No
If yes, what area was treated?
Are you prone to keloid or hypertrophic scarring?
Yes
No
Have you ever had any of the following injectables or implants?
Botox
Radiesse
Perlane
Collagen
Dysport
Juvederm
Restylane
Silicone
Sculptra
Other
If yes , When?
What body area(s)?
Have you had any recent cosmetic surgeries/procedures?
Yes
No
If yes.when? 7 What body area?
When were you last exposed to the sun (including tanning beds)?
Have you used Accutane in the past year?
Yes
No
When were you last exposed to the sun (including tanning beds)?
Do you have hyperpigmentation darkening of the skin or hypopigmentation (tightening of the skin or markes after physical trauma?
Yes
No
If yes, please describe
Do you have any tattoos in the area to be treated?
Yes
No
Have you had chemotherapy in the past 6 months?
Yes
No
Do you have any of the following condition
Psoriass
Eczema
Dermaths
Pregnancy and/or breastfeeding
Autoimmune disease
Herpes Simplex
Diabetes
Heart disease and/or heart defects
Hemophilia
Collagen Vascular disease
Active acne
Do you have any other health conditions not mentioned here?
Yes
No
If yes, please list
Do you have moles/skin growths in the area to be treated?
Yes
No
Have you ever had a reaction at the dentist or any other time from numbing
Yes
No
Do you have any allergies to medications, food, latex, topical products, and/or other substances? Please List
Have you consumed drugs or alcohol in the last 24 hours?
Yes
No
Please let at vitamins and supplements including herbal remedies you take regularly
Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly
Is there anything else you would like us to know?
I certify that the preceding medical, personal and son history statements are true and correct, I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures
Client Name
Client Name Signature
Clear
Esthetic/Technicians
Select a date
Submit
Thanks for submitting!
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