Facial Intake Form

Skincare Guest Intake

Tell us about your skin
Todays date

MonthDayYear
First NameLast Name
Phone *

Area CodePhone Number
Date of birth*

MonthDayYear
Email*
Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact *

First NameLast Name
Contact Number

Area CodePhone Number
Please choose spa wrap size preference:*

Small to MediumMedium to LargeLarge to Extra Large2XL to 3XL
Have you ever received professional skin care treatments?*
If yes, when?

MonthDayYear
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?*
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

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 RenovaGlycolic or Lactic AcidSalicylic AcidBenzoyl PeroxideIsoretinoin (Accutane)AntibioticsNONE
Have you ever received any of the following treatments*

MicrodermabrasionChemical PeelsBotox or any fillersLaser treatmentsNONE
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?*
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

MonthDayYear
Date
Please check any that apply:*

No Major Health IssuesAuto immune DisorderHeadachesHigh Blood PressureDiabetes Type 1 or Type 2SeizuresJaw Pain / Clenching/ GrindingFibromyalgiaUsed Retin -A within the past 10 days?Heart conditionEpilepsyAsthmaHepatitisHigh/Low Blood pressureAnemiaAutoimmune disorderClaustrophobiaCancerThyroid disordersFaintingHypoglycemiaOther
HydraFacial Pre & Post Instructions: (for HydraFacial guests-please read prior to service)
Signature

Clear
Please verify that you are human*
Should be Empty: