New Client Intake Form

The SWR New Client Consultation Form
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*
E-mail*
example@example.com
How did you hear about us?*
If Referral, please list name
Please list all skincare products and brands you are currently using. (Be specific)*
Are you currently on Accutane?*

YesNot anymore, but it's been less than 6 monthsNot anymore, and it's been more than 6 monthsNoNot sure
Are you currently using any prescribed topical retinoids like tretinoin or adapalene? (We recommend that you stop using all prescribed or cosmetic skincare products with retinols or other exfoliants like Glycolic, Lactic, Mandelic, Benzoyl Peroxide, Salicylic, and any scrubs for at least 3-5 days before your facial to minimize the risk of irritation).*

Yes, I use a prescribed retinol or an exfoliant nightlyYes, but not within the last 5 daysNo, I don't use any exfoliantsNot sure
Are you currently using Metronidazole gel (Metrogel)?*

YesInfrequentlyNoNot sure
Are you currently on any antibiotics?*

YesNoNot sure
Have you received any of these facial hair removal services within the last 5 days?*

WaxingSugaringThreadingElectrolysis/LaserDepliatory CreamShavingNone
Have you received Botox within the last two weeks?*

YesNo
Have you received Fillers within the last 30 days?*

YesNo
Have you ever experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart ProblemAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresLupusDepression / AnxietyHepatitisHeadaches / MigrainesOtherNone
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not applicable
Please list ALL prescribed and over the counter meds (including vitamins/supplements) you are currently taking.*
What would you like to improve about your skin? Please list any known skin conditions or skin concerns.*
Please list all known allergies
Are you a chronic skin picker?*

YesNoSometimes
Do you understand the importance of eating real, whole foods daily for healthy skin?*

Yes I understand the importance, and I do live a healthy lifestyleYes, I try to implement eating healthy when I canNo, I don't eat healthy
Do you smoke tobacco or cannabis?*

Yes, tobaccoYes, cannabisYes to bothSometimes tobaccoSometimes cannabisNo
Do you drink more than 4 caffeinated beverages per day? (tea, coffee, soda, energy drinks, etc)*

YesNo
How much water do you drink per day?*

Around 60 fl. oz or lessAround 90 fl. ozAround 120 fl. ozMore than 1 gallon per dayNot enough
Please rate your stress level*

LowMediumHigh
Are you currently taking birth control?*

YesNoN/A
If yes, what kind?
Are you pregnant or breastfeeding?*

Yes, I am pregnantYes, I am breastfeedingYes, I am pregnant and breastfeedingNo to both or N/A
I consent to pictures and/or videos being taken of my face during the facial, which may be posted on the @skinwithrobin business instagram page.*

Yes, you have my permissionMaybe, I'd like to approve the images firstNo, I do no consent
Post-Facial Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 24-48 hours. Direct sunlight exposure is to be avoided immediately following treatment. If some sun exposure is unavoidable, apply a broad spectrum sunscreen of SPF 30+ every two hours. Enzymes and chemical peels can result in skin flushing/redness, slight skin flaking or sensitivity for 48-72 hours post treatment. DO NOT peel, pick, or rub, or scratch your skin at any time. This can potentially cause damage and compromise your results.*

I have read the post-care instructions above and agree to adhere to the them.
Facial Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required to hold an appointment and will remain on file. The card will not be charged for your service until after your appointment, so you can choose a different method of payment at that time. If you fail to cancel or reschedule your appointment with at least 24 hours notice, you will be charged 100% of the service(s) booked for late cancellations. If you are currently in our "Acne Clearing Program," and we receive less than 24 hours notice of rescheduling your appointment, you will be charged $100 before we can reschedule. If you do not show up for your appointment, you will be charged 100% of the service(s) booked. If you are late to your appointment, that time will be deducted from your service and you will be charged 100% of the service(s) booked. If you are on a program payment plan and you decide to cancel or no-show at any point during the program or series, your credit card will be charged for the remainder of the program.*

I understand the reservation, cancellation, and program policies at Skin with Robin and I consent to my credit card on file being charged if I fail to meet the required cancellation policies.
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclose, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here at Skin with Robin are voluntary and I release this skin care professional, Robin Pettus, Shelby Kaneen, and all Skin with Robin employees, from liability and I assume full responsibility thereof.*

Yes, I assume full responsibility
Signature*
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The SWR New Client Consultation Form