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Intake Form
Client Profile & Medical history
FIrst name
Last name
DOB
Age
Height
Email
Phone
Emergency Contact
Describe any aesthetic services you're received in the last 6 months:
Have you consumed at least 3 glasses of water today, prior to treatment?
Yes
No, but I will have some now
How did you hear about Essential Vessel?
Check the box if you have or have had any of the following. If yes, please briefly explain:
Pregnant
Breast Feeding
HIV Aids
Bleeding Disorders
High Blood Pressure
High Cholesterol
Liver Disorders
Skin Disorders
Respiratory Disorders
Neurological Disorders
Cardiac Disorders
Lymphatic Disorders
Psychological Disorders
Diabetes
Pace Maker or Devices in Body
Metals in Body
Seizures
Cancer
Acute Illness (cold/flue/diarrhea etc.)
Other (list below)
Describe all surgeries and the year you received them:
List all allergies and your reactions:
List all medications/herbs/supplements currently or recently taken:
Specific apperance problems and treatment goals:
Skin Condition:
Dry
Oily
Normal
Acne Prone
Ethnicity
Is your skin fragile or sensitive? If yes, describe:
Do you have problems healing from injury to skin? If yes, describe:
Have you ever had a cold sore?
Yes
No
Are you primarily inside or outside?
Outside
Inside
Do you use sunblock regularly?
Yes
No
By typing my full name in the box below, I verify that I am in good physical condition and the information provided above is accurate and complete. I have no physical restrictions, conditions or disabilities which may prevent me from receiving the prescribed skin care and/or body treatment therapies. I hereby give my content to have the recommended procedures performed on me by Essential Vessel.
Type your full name:
Today's Date:
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