Facial Intake Form

Facial Intake Form
Name
Date of birth

MonthDayYear
Phone Number
Address

Street Address

Apt/suite/po box

CityState

Postal/Zip code
Email
How did you hear about us?

Social MediaFriendReferralSchoolSearch engine ( Google, Yahoo, Etc )Other
Do you have any of the following? Check all that apply.
What is your current skin care regimen ?
Have you ever had or have a type of skin cancer?
Do you consume water daily?

YesNo
Do you have any skin allergies ?

YesNo
Any surgical procedures in the past year?
Have you received laser, microdermabrasion, chemical peel recently or other resurfacing treatments in the last 72 hours?

YesNo
Are you on birth control?

YesNo
Are you experiencing any of the following ?
Have you used any of the following acne medication ? ( Roaccutane, Retin-A, Differin, Tazorac, Epiduo )

YesNo
Do you take any medications daily?
What are your current skin care concerns?
Have you tanned in the last 48 hours ?

YesNo
Have you had any waxing treatments in the last 72 hours?

YesNo
Are you pregnant ?

YesNo
Do you consume any alcoholic beverage ?

YesNo
Do you use any recreational drugs?

YesNo
Do you wear sun protection?

YesNo
I certify that all answers given are true to my knowledge. Any information that is not in my current knowledge, documented, or falsified can not be held against my service provider following procedure, if any adverse reaction should occur.
Signature

Clear
Date

MonthDayYear
Date
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