Skin Intake Form
Please answer all question
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
Your Skin Goals and Concerns:
Your Skin Type:
Normal/Combo
Oily
Sensitive
Dry
Mild Acne
Moderate Acne
Mature & Aging
What is your morning and night skincare routine?
What makeup products are you currently using?
Does your job and lifestyle require that you work/play outdoors?
Do you wax your facial skin on a regular basis?
Yes
No
If yes, when was the last time?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
Yes
No
If yes, was it within the last month?
Are you using Retin-A?
Yes
No
Are you using Benzoyl Peroxide?
Yes
No
Do you have any allergies or sensitivities?
Have you ever experienced a reaction to any of the following?
Cosmetics
Medicine
Iodine ( Shellfish)
Latex
Pollen
Food/Fruit
Animals
Fragrance
Alpha Hydroxy Acids
Sunscreens
Do you have any of the below health issues?:
Cancer
Circulatory Issues
Arthritis
Hormonal Imbalances
Diabetes
Lactating
Psoriasis
Cold Sores
Chemotherapy
High Blood Pressure
Hysterectomy
Thyroid
Pregnant
Planning to be Pregnant
Recent Surgeries
Eczema
Do you take any medications?
Are you taking any of these medications?
Accutane
Antibiotics
Birth Control
Upload picture of your skincare concerns
Browse Files
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Choose facial/body treatment add-on:
Hibiscus Flower $5
Green Tea $5
Eye Treatment $10 (facial only)
Lip Treatment $10 (facial only)
Vitamin C $11 (facial only)
Vitamin K $11 (facial only)
Hyaluronic acid $11 (facial only)
Advance Extractions $15
Hydro-jelly Mask $15
Advance Facial Massage $20 (facial only)
Signature
Submit
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