Cosmetic Acupuncture and Facial Cupping Intake Form

Date of birth*

Name*

First Last

Phone*

Please provide us with the phone number for which you are most easily reached.

Email*

How did you hear about us?*

Referral

If you have been referred, please let us know by whom so we can thank them.

Have you had acupuncture before?

Yes
No

Occupation

Your Health

If yes, please specify.

Have you had any health problems in the past or present?*

Yes
No

If yes, please specify.

List any medications, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.*

Do you have any allergies?*

Yes
No

If yes, please specify.

Do you any problems with bleeding or bruising?

Yes
No

Do you follow a restricted diet?

Yes
No

If yes, please specify your restrictions.

Do you smoke?

Yes
No

On average how much water do you consume daily?

On average how many alcoholic beverages do you consume weekly?

On average how many caffeinated beverages do you consume daily? (coffee, tea, soft drinks)

Do you exercise regularly?

Yes
No

If yes, please specify how many times per week.

Do you wear contact lenses?

Yes
No

Do you sunbathe or use tanning beds?

Yes
No

If yes, how often?

Have you experienced claustrophobia?

Yes
No

Within the last 9 months have you been undergone surgery?

Yes
No

What is your pain threshold?

1 being quite low and 5 being quite high.

Please enter a number from 1 to 5.

What massage pressure do you prefer?

Light
Medium
Firm

Your Skin

Check off all the specific skin concerns/ challenges that apply.

fine lines
wrinkles
redness
brown spots
loss of firmness
acne
other

Please share any further details regarding your goals for your visit.

What skin care products are you currently using?

Other makeup:

Body products

bar soap
shower gel
scrubs
oil
body moisturizer
depilatory products
self-tanner

Do you use facial tools? eg: gua sha, facial rollers, microneedler, nuface, cleansing brush etc.

Yes
No

If yes, please specify which and how often:

Have you ever had:

chemical peel
microdermabrasion
laser
intense pulsed light
dermaplaning
microneedling

If yes, please specify which and when you last received this treatment.

Do you use: Retin-A, Renova, Adapalene or any other prescription skin products?*

Yes
No

If yes, was it in the last 3 months?

Yes
No

Are you currently using products that contain any of the following ingredients?

hydroxy acids (glycolic, lactic, salicylic etc.)
exfoliating scrubs
vitamin A derivatives (Retinol, Retin-A, Retinyl Palmitate)

Do you ever experience these conditions on your skin?

flakiness
tightness
obvious dryness

Do you use sunscreen daily?

Yes
No

If yes, please specify what SPF you use for both face and body.

Choose which best describes your skin’s response to the sun.

always burns, blisters and peels
often burns, blisters and peels
burns moderately
burns rarely, if at all
never burns

Have you ever been diagnosed with melasma?

Yes
No

Do you have a tendency to flush/ experience skin redness?

Yes
No

Have you ever been diagnosed with rosacea?

Yes
No

Do you ever experience a burning, itching, or stinging sensation on your skin?

Yes
No

Hormonal Health

These questions can help us determine sensitivity to aspects of the treatment or possible contraindications to treatment.

Do you use hormonal contraceptive?

Yes
No

If yes, please indicate for how long.

Are you pregnant or trying to become pregnant?

Yes
No

Are you currently having or due for your menstrual period?

Yes
No

Are you undergoing medically supervised hormone therapy?

Yes
No

Client Waiver*

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. By my signature below, I give consent for esthetic services rendered by Collective Skin Care and its affiliates.
I have been informed and advised of all risks associated with the services and procedures I will be receiving*.
I agree to comply with the instructions provided by the service provider.
I understand that I am responsible to find out the amount (limit) of my insurance coverage, and that I am responsible to cover all treatment fees and submit for reimbursement from my insurance provider according to my insurance agreement.

*Information about potential risks is provided through Collective Skin Care's online booking system.

Consent*

I hereby release Collective Skin Care, its affiliates and directors from liability for any injury, loss or damage that may result from any services provided or treatments rendered. This release binds my heirs, successors and assigns.

Cancellation policy and credit authorization release*

We request 24 hours notice for cancellations or appointment changes. Cancellations within 24 hours of the scheduled service are subject to a charge equal to 100% of the booked appointment.

I understand the cancellation policy and agree to pay any cancellation fees I incur.

Comments

This field is for validation purposes and should be left unchanged.

Cosmetic Acupuncture and Facial Cupping Intake Form

Cosmetic Acupuncture Form

Cosmetic Acupuncture and Facial Cupping Intake Form

Your Health

Your Skin

Hormonal Health

PARKING