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Clear Esthetics
Medical History Intake Form
Today's Date
*
Month
Month
Day
Year
First name
*
Last name
*
Date of Birth
*
Month
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
No
Active Acne or Skin Inflammation? Avoid treatments that can irritate or spread acne.
*
Yes
No
Are you pregnant or planning to become pregnant? Some treatments and products are not recommended during pregnancy
*
Yes
No
Do you have any autoimmune disorders? Conditions like lupus or rheumatoid arthritis may affect treatment suitability.
*
Yes
No
List any recent cosmetic procedures. Recent chemical peels, laser treatments, or surgeries may require a waiting period.
*
Submit
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