Health Intake Form

  • Welcome! Please complete this Intake to the best of your ability both prior to your first session at Sesen Skin Body Wellness and any time your health information has changed. The health and lifestyle topics addressed herein ALL have the potential for affecting your skin or causing interactions with aspects of your treatment at the Sesen.
    Keep in mind that incorrect or incomplete health records can lead to adverse skin reactions even with the most capable Esthetician.
    Your Health Intake and Treatment Notes are held in the strictest confidence.
  • Please enter as mm/dd/yyyy
  • Click on the plus(+) at the end of the line to add items.
    ProductNameBrand 
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    ProductName 
  • 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 irritations to the skin from the treatments received. Professional Estheticians make many judgment calls during the course of treatment. We are trained to customize office and home treatment plans to maximize the health and beauty of your largest organ. Having an up to date health history enables us to make the safest, best choices as we treat your skin, so that you may enjoy the benefit of our full range of knowledge. I am aware that it is my responsibility to inform the Esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Sesen Skin Body Wellness from liability and assume full responsibility thereof.

    I understand that requests to cancel or reschedule appointments are gladly accommodated with 24 hours notice and that short notice cancellations (less than 24 hours) and no shows will be charged.
  • Please sign using your mouse, or finger if using a touch screen.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.