• New Client Intake Form

  • Current Date*
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  • Date of Birth*
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  • How did you hear about Nomadic Skincare?*
  • Do you work nights?*
  • Do you agree that Nomadic Skincare can use images of you and any before, after, or progression photos of any services performed for marketing, portfolio and website content purposes?*

  • Your Skin Health and History

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  • What do you feel is your skin type?*
  • What are your current skin concerns? (select all that apply)*
  • What Skin Care Products do you currently use? (select all that apply)*
  • When you go out in the sun, do you...*
  • Have you ever had a facial or skin treatment before?*
  • Have you received any of the following facial treatments in the past 3 months?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
  • Have you received any Botox, Juvederm, Collagen, or other dermal fillers in the past month?*
  • Have you been under the treatment plan of a dermatologist or plastic surgeon in the past year?*

  • Your Health

  • Do you have a history of or are you currently experiencing any of the following conditions? (check all that apply)*
  • Do you:*
  • Do you take any of the following dietary / health supplements?
  • Any known topical or relevant allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • Are you a cigarette smoker?*
  • How much alcohol do you consume in a week?*
  • Do you drink more than 2 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
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  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Are you undergoing any hormone replacement therapy? *
  • Should be Empty: