Skincare Guest Intake
Tell us about your skin
Todays date
-
Month
-
Day
Year
*
First Name
Last Name
Phone
*
-
Area Code
Phone Number
Date of birth
*
-
Month
-
Day
Year
Email
*
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact
*
First Name
Last Name
Contact Number
-
Area Code
Phone Number
Have you ever received professional skin care treatments?
*
Please Select
Yes Facial
No Facial
Yes Peel
No Peel
Yes waxing
No waxing
If yes, when?
-
Month
-
Day
Year
Date
Do you have any specific concerns regarding your skin?
Do you have any specific goals for today's session?
What skin type would you say you are?
*
Normal/Dry
Normal/Oily
Mature
Sensitive
Acneic/Hormonal
Rosacea
Combination
Other
Select from list
What is your daily skin care regimen?
*
What skin care products are you currently using?
*
What is your stress level in general?
1
2
3
4
5
Not much
Off the charts
1 is Not much, 5 is Off the charts
Are you presently using or recently used any of the following. Check any that apply:
*
Retinol or Retin A or Renova
Glycolic or Lactic Acid
Salicylic Acid
Benzoyl Peroxide
Isoretinoin (Accutane)
Antibiotics
NONE
Have you ever received any of the following treatments
*
Microdermabrasion
Chemical Peels
Botox or any fillers
Laser treatments
NONE
Known allergies or sensitivities (food, botanical, none,etc)
*
Are you taking any medications, supplements, or herbal remedies?
Are you presently under a physician's care?
*
Yes
No
If yes, please provide specifics
Please provide any health conditions you have experienced in the last three years or are experiencing now:
Date of last menstruation
-
Month
-
Day
Year
Date
Please check any that apply:
*
No Major Health Issues
Auto immune Disorder
Headaches
High Blood Pressure
Diabetes Type 1 or Type 2
Seizures
Jaw Pain / Clenching/ Grinding
Fibromyalgia
Used Retin -A within the past 10 days?
Heart condition
Epilepsy
Asthma
Hepatitis
High/Low Blood pressure
Anemia
Autoimmune disorder
Claustrophobia
Cancer
Thyroid disorders
Fainting
Hypoglycemia
HydraFacial Pre & Post Instructions: (for HydraFacial guests-please read prior to service)
Signature
Clear
Please verify that you are human
*
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