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 + brands you are currently using. (Be specific)*
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives*

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 60 daysNoNot sure
Have you ever received chemical peels, laser services, or microdermabrasion treatments*

Yes, within the last monthYes, within the last 2-3 monthsYes, but not within the last 60 daysNo
Have you received any of these facial hair removal services within the last 5 days?*

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

YesNo
Have you received any Fillers in 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 ProblemArthritisAuto-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
If other, what's the reason:
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. oz1 Gallon+ per dayNot enough
Please rate your stress level*

LowMediumHigh
Are you taking birth control?*

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

Yes, I am pregnantYes, I am 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 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. Enzyme peels and chemical peels can result in skin flushing/redness, slight skin flaking or sensitivity for up to 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.
Post 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 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.*

I understand the reservation and cancellation policies at Skin with Robin and 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 are voluntary and I release this skin care professional (Robin Pettus) and all Skin with Robin employees, from liability and assume full responsibility thereof.*

Yes, I assume full responsibility
Signature*

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The SWR New Client Consultation Form