Intake Form

Intake Form
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gander*

MaleFemale
Occupation
Referred by
Do you have any health problems? *
Do you wear contact lenses?*

YesNo
Are you taking medication and/or hormones?*
Do you have any special skin problems pertaining to your face or body?*

YesNo
Describe your skin:*

Large PoresSmall PoresSun DamageUneven/BlotchyPost InflammatorySensitiveWrinkledFreckledMature AcneHypo-pigmentedHype-pigmentedResilientSaggyMelasmaComedonesNormalCysticAsphyxiatedFirmPerfume Stained DryT-zone / CombinationSallowScarredRosaceaOccasinal BreakoutsMiliaOilyFloridOther
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?*

YesNo
In the last month?*

YesNo
Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin product?*

YesNo
In the last 3 months?*

YesNo
Are you currently using any products that contain the following ingredients?*

Glycolic acidAny hydroxyl acidLactic acidAny exfoliating scrubsVitamin A derivatives(i.e. retinol)
Are you pregnant or trying to become pregnant?*

YesNo
What is your primary concern? *
Signature

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