Esthetician Intake

Please check all that apply:
AcneArthritisDepressionDiabetesEczemaEpilepsyFever BlistersHeart ConditionHepatitisHigh Blood PressureHIV HyperPigmentationHypo PigmentationInsomniaLow Blood PressureLupusSinus InfectionPregnantPsoriasisRashesSeborrheaShinglesSkin CancerSurgeryHyper/Hypo ThyroidWartsOther

Check the products that you currently use (please select all that apply):
Body LotionBody SoapBody ScrubCleansing CreamDay CreamEye Makeup RemoverEye CreamExfoliantsFacial SoapFacial ScrubHand CreamNeck CreamNight CreamSkin Toner/AstringentOther

What type of skin do you have?
NormalOilyDryCombinationUnsure

Conditions you are currently experiencing today (please select all that apply):
AnxietyFatigueForgetfulnessHeadacheInflammationInsomniaMuscle CrampsStress

What concerns do you have regarding your skin? Please select all that apply:
Blackheads/WhiteheadsClogged PoresDrynessRednessScarringUneven Skin ToneWrinkles/Fine LinesAcne/BreakoutsBroken CapillariesDark SpotsExcessive Oil/ShineRosaceaSun DamageUnwanted HairOther

• I acknowledge that I have received a copy of Radiant Recharge LLC's HIPAA Privacy Notice.

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.