Skin Questionnaire
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Please list allergies.
Please list medications.
Are you sensitive? Does your skin get red easily?
When was your last facial? What kind of facial?
How often do you like to get facials/skin care treatments?
Have you had any Botox, Laser, or Chemical Peels recently? If so please include which one.
Please list any medical conditions you are currently being treated for.
Please list your complete skin care routine and brands.
Are you taking any dermatologist prescribed topical or oral medication such as Accutane, retinol, etc?
Are you using birth control?
Yes
No
Are you pregnant, think you may be pregnant, or breastfeeding?
Please list any recent surgeries.
What are your skin care concerns?
Dryness
Acne
Wrinkles
Enlarged Pores
Elasticity and Lifting
Redness/Rosacea
Uneven Texture
Dark Under Eye Circles
Oily Skin
Sun Damage/Hyperpigmentation
Blackheads
If there is anything you would like to change or improve in your skin what would it be? What are your skin care goals?
Would you like for your esthetician to recommend professional skincare and treatments to achieve your skin care goals?
Do you feel committed to improving the look and health of your skin and reaching your skin care goals?
What are you interested when it comes to facials? Please pick one answer.
I am wanting to take care of my skin on a consistent basis, want skincare recommendations and improve my skin.
I just want relaxation.
I just like to get them every once in a while.
Do you currently have a consistent esthetician treating your skin?
Do you sunbathe or participate in outdoor activities?
How much water and caffeine do you drink daily?
Do you take any supplements/herbs? If so what kind?
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician for this procedure and due to any misrepresentation of my health history which is performed with utmost attention to safety and sanitation. By initialing I grant the service provider permission to take any before and after pictures as well as any video for social media, print, or promotion of the service or any products used in the service.
Initial:
Signature
Parent Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: