Consultation

NEW CLIENT INTAKE FORM

SKIN HEALTH QUESTIONNAIRE
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date

MonthDayYear
Occupation
How did you hear about The Houston Facialist?
If referral, please list name.
Please indicate which of the following you are interested in:

Other
What are your skin goals?
Have you ever had a facial or skin treatment before?
If yes, when?
Have you currently or previously ever experienced the following, check all that apply.
If you are currently experiencing or being treated for any health or skin-related condition/disorder, please describe:
Please indicate if you have ever used any of the following medications for skin treatment (check all that apply):
What condition were you treating with this medication, and when was the last time it was used?
Do you have any known allergies? Also, list any skin treatment products you have used that caused an unexpected reaction or side effect:
Please list all over-the-counter medication, supplements, and/or prescription medications you are currently taking:
Do you have any permanent cosmetics or tattoos on the areas being treated?
If yes, please list area(s)
Women

Female and female-identifying clients please fill out the following:
Are you currently pregnant?
Are you currently breastfeeding?
Are you going through menopause?
Are you currently on any type of hormone therapy or birth control?
If yes, please describe:
Skin Self Analysis
Is your skin (check all that apply)
What skincare products are you currently using? Please list what type of product (cleanser, toner, etc), the brand, and how you use the AM/PM.
Are you currently wearing daily sunscreen?
Lifestyle & Stress Analysis
Do you recieve Botox/Filler injections? If yes, how long since last injection?
Do you use tanning beds?
Do you smoke or vape?
What is your stress level?
How much water do you drink daily?
What is your average hours of sleep a night?
Please indicate any of the following that apply to your eating habits:
I consent to "before and after" photos for the purpose of documentation and to post on social media.
I have answered the above questions truthfully and to the fullest extent of my knowledge, and I understand agree that I am ultimately responsible for payment in full for services received.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
File Upload

Take pictures of your right side, left side and a front view of your skin.
Cancelof
Client Siganture
Should be Empty:

NEW CLIENT INTAKE FORM

Women

Skin Self Analysis

Lifestyle & Stress Analysis