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New Client

Intake Forms

All New Clients are REQUIRED to fill out our "General Intake Liability Form" to have on record with us.

Please use the Forms menu to choose any forms that match the Treatment(s) you have booked and fill in as applicable.

General Intake Liability Wavier

Birthday
Month
Day
Year

In order to provide you with the most appropriate esthetic treatment, we need you to complete the following questionnaire. All information is strictly confidential.

Gender
Do you have any metal implants in your body?
Have you had any Liposuction?
Have you had any Body, Face or Neck Lifts or Modifications?
Any surgeries not listed above?
With any surgeries was drainage used as part of your recovery?
Do you have any issues with Balance or Mobility

Please list any current health issues you may have. Certain Treatments may be contraindicated in combination with certain health issues.

(Please Check the Continue Box to proceed to answers)

Do you have any Allergies?
Are you currently taking any over the counter Herbal Supplements?
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, Salicylic Acid or Retinol or similar treatments?
Do you sunbathe or use a tanning bed on a regular basis?
Have your recently used any self-tanning lotions, creams, sprays or similar treatments?
Do you use Sunscreen on a regular basis?

Additional information and comments:



At It's Me Time our clinical facials and/or body treatments may consist of a surface cleansing, exfoliation using a scrub, enzymes or a chemical exfoliation, extractions (if needed), mask application, corrective serums and SPF.  In addition, the following equipment may be utilized: Microdermabrasion, Dermaplaning, HydraBeauty, Micro-Channeling. I will ask the technician about any treatment being performed on me beforehand in which I do not fully understand.


Clinical treatments take approximately thirty minutes to one hour to complete and are designed to restore skin health and beauty as much as possible in the scheduled time. Although, these services are known to be safe, I understand that the service may involve risk of complications or injury from known or unknown causes, and I freely assume these risk.


I attest that I will not hold It's Me Time or its staff liable for any adverse outcome as a result of omissions to my medical history, surgical and procedure history, medications, allergies, and pregnancy status (as applicable). I also attest that I will inform It's Me Time or its staff of any changes related to my medical or pregnancy status and have been advised on how to contact the physician or nurse directly and agree to report any post-treatment adverse effects immediately. 


I understand that there are known temporary side effects after treatment including redness, swelling, bruising, discomfort, darkening of pigment lesions and spider veins which can last a few hours to several weeks. There is also a possibility of temporary lighter or darker skin discoloration (hypopigmentation or hyperpigmentation - dark spots). I understand that there is a slight possibility (although extremely rare) that these effects may be permanent.


I have informed my skin care specialist of any health problems of which I am aware, and all medications I am taking, particularly Accutane, Retinoids and topical prescription drug therapies.


I understand that skin rejuvenation is best achieved through a series of recommended treatments and compliance to the home care product program recommended by my Skin Care Specialist.


I understand that all sales are final and no refunds will be issued.

New Client

Intake Forms

Manual Lymphatic Drainage Intake

Have you ever received Manual Lymphatic Drainage before? *

Single choice
Yes
No

What are your goals for this treatment? *

Have you had any surgery?

If yes, for what and when?


With any surgeries listed above were drains used following the procedures?

Did your surgeon recommend post-surgical MLD?

If yes how many treatments were recommended?


Have you been referred by your doctor to receive MLD?

How many sessions?


Are you experiencing any swelling or bruising? *

If so where?

Are you in pain? *

Single choice
Yes
No

If yes where?

We are not able to provide this service to individuals that have:


- Active Cancer (If it has been removed and we have a doctor's approval, we are then able to provide MLD)


- Deep Vein Thrombosis (DVT)


- Acute Infection or Inflammation



I agree to let my aesthetician know:


- When and if I am menstruating (MLD could make period heavier)


- If I have Low Blood Pressure or Hypothyroid (May cause fatigue or/ fainting)


*Detoxing Symptoms-  By signing I understand that there may be some side effects to MLD including but not limited to; headaches, nausea, body aches, and/or chills. You can use your own discretion when taking over the counter pain killers. Dehydration can happen easily with MLD. 120 oz of water (including tea) is required by the end of the day of service.  Hydrating with electrolytes and some herbal teas can also help these side effects. The most common side effect is feeling sleepy and very relaxed, so take it easy and limit any stressful activities. 


**Cancer patients can ask their doctor about manual lymphatic drainage. Many are referred to MLD from their doctor and continue therapy after remission for preventative care. We just need approval by you or your physician to perform the therapy if you have or have had cancer. 


Some insurance plans also cover the cost of monthly sessions we are included as massage and happy to provide receipt.


Specifics;


Amount of sessions and frequency is up to the client. We generally recommend six or more. Continued monthly sessions are also suggested.


All clients should abstain from coffee, energy drinks of any kind, and alcohol. Any caffeine should be herbal(tea) and/or adaptogenic. Red/Infrared Light Therapy is recommended for those who suffer fatigue. These are not contraindications, but important information for long lasting results and long term recovery.


Avocado, Olive, Coconut, Ghee, and Butter are considered safe fats. We also recommend following a diet listed for your blood type. Herbal tea may also be recommended for certain conditions.


Brisk walking, hiking, dancing, low intensity work outs, stretching, lymphatic brushing, infrared light, shake plate, grounding, and all water play are excellent for continued progress.

I have read and answered all the questions to the best of my abilities. If and when there is a change to these answers, I agree to inform It's Me Time staff: *

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