Client Intake Form, Client Information Sheet, and Medical History Questionnaire are all acceptable titles for this document as they all essentially mirror each other in meaning: gathering client information.
CLIENT CONTACT INFORMATION
The client contact section of the intake form typically gathers the client's name, address, date of birth, emergency contact, phone number, and e-mail address. It is important to obtain this information for several reasons, including confirming their appointments and reaching out for ongoing contact, such as promotions, surveys, and social events.
Common e-mail campaigns include welcoming new clients; celebrating birthdays, anniversaries, and holidays; sending "We miss you" e-cards; and thanking the most loyal clients. These campaigns can be easily created and sent out on the professional's behalf by several web-based software programs that pull client information several times daily from the spa's client management and scheduling software to generate a list of clients who will receive these e-mails. The great thing about these type of software systems is that all of the reporting and information gathering is done for the professional while they do what they do best: meeting with clients. Professionals simply ensure that the client information is entered into their software system completely and correctly, create their e-mail campaigns, and the software will do the rest.
The medical history section of the client intake form should be specific to the indications and contraindications of the services the spa offers. Almost everyone has been to a primary care physician and completed the dreaded clipboard full of forms. Primary care physicians treat a multitude of conditions for their patients and require a lot information from patients in order to perform a thorough evaluation. The physician's medical history section of the client intake form is typically much more lengthy in gathering a patient's medical history than a spa or medical spa as there are many possible diseases and conditions the patient may have that the physician would be treating.
Spas typically do not require the extensive amount of information that a physician would require on the medical history section of the intake form because spas do not treat the diseases and conditions that a physician practicing general medicine does. However, the medical history section could become quite lengthy if the spa offers a full menu of treatments, such as facials, massage, cosmetic injections, cosmetic laser and light-based treatments, microneedling, radio frequency, or hormone therapy treatments.
The specific questions the professional uses in their medical history section should not only be based on the services they offer, but also on the general health of the prospective client. Almost all medical history forms ask questions regarding general medical conditions – such as if the client has high blood pressure, heart conditions, or skin conditions or if they have had any recent surgeries – in addition to routine questions regarding the medications the client is taking.
When it comes to service-specific questions, the history may ask about specific conditions, medications, and general health.
When it comes to facials, the client intake form should ask whether clients have had any recent hair removal treatments or procedures performed on the skin, such as laser or cosmetic injections. It should also inquire about their use of skin care products that contain vitamin A or oral medications, like Accutane. Questions about the client's skin type (dry, oily, or sensitive) and the amount of water they consume daily are also important for the professional to know.
Why are these questions important to ask in order for a client to receive a facial? Procedures and products that could irritate the skin are important to know prior to administering the service to ensure that the client is not at risk for potential injury to the skin. Waxing, vitamin A products (Retin-A), Accutane (isotretinoin), and laser procedures could cause skin sensitivity and could result in an adverse event, such a hyperpigmentation or scarring. Additionally, many cosmetic injections typically require a two week wait after the injection before receiving any procedure in the treated area to ensure there is no disturbance of the injected products.
Laser and light-based therapies, such as laser hair removal, IPL, and certain skin-tightening procedures, also have specific questions on the medical history form to ensure the client receives a safe and effective outcome from the treatment. Many of the laser and light procedures require the client to avoid prolonged sun exposure to the treatment area for two weeks. Finding out a client's skin response to prolonged sun exposure is also very important for the professional as tanning habits can indicate the skin's sensitivity.
Topical products, oral medications, and supplements that can cause the skin to become photosensitive are also contraindicated for most laser and IPL procedures. For example, Accutane is contraindicated for at least six months prior to a laser treatment. Vitamin A skin preparations are also photosensitizing and are contraindicated for several days. Along with topical products and oral drugs that may cause photosensitivity, previous skin treatments or cosmetic injections may also require a waiting period prior to performing laser or light-based therapies in the same area. The rule of thumb is to ensure the client has healthy, hydrated skin that is intact. Peeling, cracked skin; active acne; and sunburned skin are a few examples of what to avoid for most laser treatments.
Certain skin conditions may also be contraindicated for cosmetic laser and IPL procedures. Psoriasis in the treatment area, ringworms, active herpes, and eczema are common skin conditions that may prevent a client from being treated. IPL procedures are contraindicated for those that are prone to seizures due to the bright strobe-like flash of light that is emitted from the handpiece.
Radio frequency procedures are popular and effective means of tightening the skin and smoothing the appearance of cellulite. Clients with pacemakers may not be ideal candidates for certain radio frequency procedures. Medical history forms would need to ask clients specific questions for laser and IPL procedures to ensure the client is a good candidate.
Cosmetic injections are popular and always in demand. Botulinum toxins that relax muscles are a wonderful way to smooth lines and wrinkles on the face or neck. Dermal fillers or implants also are quite popular and, in many cases, are injected along with Botulinum toxin injections in the same appointment. Dermal filler injections provide volume and lift to the skin and are ideal for plumping deep lines and lips. If the spa plans to add cosmetic injections to their list of services, there are certain questions that will need to be added to medical history section to ensure a safe and effective treatment outcome. Manufacturers of these products provide professionals with a list of contraindications that they can add to their client intake form in the medical history section. One contraindication for neurotoxins is ALS or Lou Gehrig's disease. Clients with nerve or muscle conditions are typically not ideal candidates.
All recent surgeries should be documented in the medical history section as well. Recent surgery may be a contraindication if it is near the treatment area. Ideally, the skin care professional should wait until the client's surgeon has provided a release for treatment. The spa's treatment protocols should have specific guidelines as to how many weeks post-surgery a client must be prior to treating the area.
Aside from certain facials and massage, pregnant clients are not recommended for most treatments, as the risks outweigh the benefits. Be sure the medical history section not only asks if they are currently pregnant, but also if they are planning to get pregnant. A client may need to suspend current procedures that are contraindicated until post-pregnancy and breastfeeding.
Identifying if a client has a hormone imbalance is important to determining if they are a good candidate for certain procedures and to set proper expectations for their treatment outcome.
Lifestyle and Hobbies
Asking the client about outdoor sun exposure, whether it is from working outdoors or regularly playing sports, is a good way to decide which procedures would be best and which ones should be avoided due to high risk.
PHOTOGRAPHS AND COMMUNICATIONS
Always ask clients for permission to photograph them and share their images. Request permission to text and e-mail them confirmations and promotions as well.
Adding a full disclosure to the client intake form is a good way to ensure clients do not omit or provide misinformation that, if known, would have prevented or altered the type of recommended procedure. This disclosure should be included along with a release of liability for the spa and its employees in case of an adverse event from any omissions or altered information. Be sure to have an attorney review the client forms prior to using them.
Cosmetic procedures are elective, not necessary. If there is any potential risk to the client that can be avoided, it is best to do so. Identifying contraindications and discussing them with the client is professional and clients will appreciate that the spa is not taking a risk just for money.
Rolling the dice and treating a client with a known contraindication is not worth the possible outcome of an adverse event. Insurance companies may not cover the spa if its skin care professionals treat clients with known contraindications. It is important for professionals to read their insurance policy; many do not realize what is and is not covered.
Carefully read the client's intake form and update any changes every visit. It has the crucial information professionals need to make the best treatment plan for their clients. Customizing this form to the spa's specific products and services is a great practice and allows professionals to determine procedures that are safe and effective for their clients.
Christa Hopson Murray is the president of MedSpa Advisor, a medical spa consulting company located in Texas. Murray has been involved in the aesthetic laser community for over 13 years and has managed multiple medical spas in Texas. Specializing in aesthetic laser and light-based procedures, her expertise in performing various treatments allows her to have a working knowledge of all aspects of a medical spa. Murray is a Texas Department of State Health Services registered Laser Hair Removal Professional, as well as a Laser Safety Officer. Murray was one of the first State Approved Aesthetic Laser instructors in Texas. medspaadvisor.com