Skin Intake Form
Please answer all question
Emergency Contact Phone Number
Date of Birth
Your Skin Goals and Concerns:
Your Skin Type:
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?
If yes, when was the last time?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
If yes, was it within the last month?
Are you using Retin-A?
Are you using Benzoyl Peroxide?
Do you have any allergies or sensitivities?
Have you ever experienced a reaction to any of the following?
Iodine ( Shellfish)
Alpha Hydroxy Acids
Do you have any of the below health issues?:
High Blood Pressure
Planning to be Pregnant
Do you take any medications?
Are you taking any of these medications?
Upload picture of your skincare concerns
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)
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