FACIALS - CLIENT INTAKE AND CONSULTATION FORM

Current Skincare & Medical Information

Please answer the following questions so your treatment can be safely customized to your skin.
Full Name:
DOB

MonthDayYear
Date
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail Address:
example@example.com
What are your top 2 skin concerns or goals for today's visit?
How would you describe your skin? (check all that apply)
Please list all skincare products you currently use (cleanser, toner, serums, retinol, exfoliants, SPF, prescriptions)
Do you wear makeup regularly? If yes, please list foundation, concealer, powder, or mineral makeup brands.
Does your job and/or lifestyle require that you work/play outdoors?
If yes, how much time outdoors?
Do you wear sunscreen daily?
Do you have any allergies or sensitivities? (select all that apply)
DO YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS? (select all that apply)
Please list any other medical conditions, allergies, or medications we should know about.
Are you currently using any of the following medications or active skincare ingredients? (Check all that apply)
Have you received any of the following within the last 30 days? (Check all that apply)
Birth Control?
I give permission for Viso Bello Spa to use before-and-after photos for educational and marketing purposes. My identity will not be disclosed without additional consent.
Initial here
Date

MonthDayYear
Date
By signing below, I confirm that the information provided is accurate and that I consent to today's treatment.
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Current Skincare & Medical Information