Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gander
*
Male
Female
Occupation
Referred by
Do you have any health problems?
*
Do you wear contact lenses?
*
Yes
No
Are you taking medication and/or hormones?
*
Do you have any special skin problems pertaining to your face or body?
*
Yes
No
Describe your skin:
*
Large Pores
Small Pores
Sun Damage
Uneven/Blotchy
Post Inflammatory
Sensitive
Wrinkled
Freckled
Mature Acne
Hypo-pigmented
Hype-pigmented
Resilient
Saggy
Melasma
Comedones
Normal
Cystic
Asphyxiated
Firm
Perfume Stained Dry
T-zone / Combination
Sallow
Scarred
Rosacea
Occasinal Breakouts
Milia
Oily
Florid
Other
What kind of skin care products are you currently using?
*
What is your cleansing routine?
*
Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?
*
Yes
No
In the last month?
*
Yes
No
Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin product?
*
Yes
No
In the last 3 months?
*
Yes
No
Are you currently using any products that contain the following ingredients?
*
Glycolic acid
Any hydroxyl acid
Lactic acid
Any exfoliating scrubs
Vitamin A derivatives
(i.e. retinol)
Are you pregnant or trying to become pregnant?
*
Yes
No
What is your primary concern?
*
Signature
Submit
Should be Empty: