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Copyright 2013 Orsi Skin Care Tel : 646-620-9669 or 702-803-6205 2700 E. Sunset Rd. Suite 33 Las Vegas, Nevada 89120
Intake Form
Please complete the intake, before your treatment so we can spend more time with your treatment.
Full Name
*
Phone Number
*
Email Address
*
Date Of Birth
*
Todays Date
*
What would you like to achive from your treatment today?
*
What areas of concern do you have regarding your skin?
Breakouts
Blackheads/Whiteheads
Excessive oil/Shine
Rosacea
Broken capillaries
Redness
Sun Spot/ liver spot/ brown spot
Uneven skin tone
Wrinkles/fine lines
Flaky skin
Dehydrated
Eyes
Dehydrated
Wrinkles
Puffiness
Dark cirkles
Have you ever had an allergic reaction of the following?
*
Cosmetics
Medicine
Food
Animals
Sunscreen
Iodine
Pollen
AHA's
Fragrance
Shellfish
Latex
Drugs
None
Any other allergies not listed above?
*
Have you ever have chemical peels, laser or microdermabrasion?
*
Yes
No
In the last month?
*
Yes
No
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A deriactive products?
*
Yes
No
If yes please explain
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
*
Agree
Guest Signature
*
