Health History Intake Form - The Ink Academy

Date *

Name *

First

Last

Date of Birth *

Address *

City *

Province *

Postal Code *

Age *

Phone Number *

Email *

Known Allergies and Reactions *

Please Check off if you are Taking Medication For any of the Following or have any of the Following Conditions *

Do You Smoke *

Do You Wear Contacts *

Do You Follow a Restrictive Diet *

If you follow a restrictive diet please provide a description

What Is Your Daily Consumption of Water in Oz? *

What is Your Daily Consumption of Alcohol in Oz *

Are You Currently Under the Care of a Physician or Dermatologist *

If you are currently under the care of a physician or dermatologist please explain

Have You Had Any Surgeries in the Past 6 Months? *

If you have had any surgeries in the past 6 months please explain

Any Dermal Injections/fillers Within the Last 6 Months? *

If you had dermal injections/fillers within the last 6 months please explain

Are you using any products that contain Retin –A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product? *

Have You Used Any of These Products in the Last 3 Months? *

If you've used any of these products in the last 3 months please explain

Have You had Any Allergic Reactions to any Skin Products? *

If you have had allergic reactions to any skin products please explain

Client Consent: *

I understand, have read and completed the 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 am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential. The treatments I receive here are voluntary and I release The Ink Academy from any liability and assume full responsibility thereof.

Photographic Consent: *

I consent to photographs being taken before, during and after each procedure. I agree to these photos being stored electronically in my case file and will be used only with my written consent for promotional purposes.

Patch Test Waiver *

I understand that a skin test can determine whether or not I will experience a reaction to the products used within 48 hours prior to the treatment. However, I accept this will be inconclusive as to whether I have an allergic reaction at any time in the future.

Allergy Waiver *

I waive my option to an allergy test and wish to proceed with treatment.
I have undergone or been offered an allergy test prior to my initial treatment. I therefore release The Ink Academy from liability related to any allergic reaction I may experience associated with either the application of the pretreatment cream or any other products used before, during and after my procedure, immediately or at a later date.

In case the case of an emergency , please contact: *

Name

Emergency Contact Phone Number *

Electronic Signature (Type first and last name to constitute your acceptance of these terms) *