Clear Esthetics Intake Form | Bodyology BodySculpt

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Clear Esthetics
Medical History Intake Form

Today's Date*

Month

Day

Year

First name*

Last name*

Date of Birth*

Month

Day

Year

Address*

Phone*

Email*

Emergency Contact

Name*

Emergency Contact Phone*

Relationship*

Physician Information

Physician's Name*

Physician's Phone Number*

Are you currently under the care of a physician? If so, for what medical condition?*

List all medications currently taking. Certain medications like Accutane (isotretinoin) can make the skin more sensitive*

List all allergies and/or any known allergies related to products or ingredients used in treatments*

Skin type/conditions:*

Normal

Dry

Dehydrated

Mature

Thin Sensitive

Oily

Open Pores

Comedones (black heads)

Milium (white heads)

Asphyxiated (blocked pores)

Scars

Photoaging

Superficial lines

Deep lines

Elasticity

Couperose ( broken capillaries)

Discoloration

Signs of Rosacea

Please explain location for each box checked. Eczema, psoriasis, rosacea, and severe sunburn should be assessed before proceeding.*

Open wounds or infections? Please note: any open wounds or infections should not be treated*

Yes

Active Acne or Skin Inflammation? Avoid treatments that can irritate or spread acne. *

Yes

Are you pregnant or planning to become pregnant? Some treatments and products are not recommended during pregnancy*

Yes

Do you have any autoimmune disorders? Conditions like lupus or rheumatoid arthritis may affect treatment suitability. *

Yes

List any recent cosmetic procedures. Recent chemical peels, laser treatments, or surgeries may require a waiting period.*

Clear Esthetics Medical History Intake Form

Clear Esthetics
Medical History Intake Form