Client Intake Form
Facial Service
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
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2012
2011
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1925
1924
1923
1922
1921
1920
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Referred by:
*
Please Select
Google
Social Media
Client referral
Other
Your Health
Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other physician’s care?
*
Yes
No
If yes, please specify:
Have you had any health problems in the past or present?
*
Yes
No
If yes, please specify:
Do you have any allergies?
*
Yes
No
If yes, please specify:
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?
*
Do you smoke?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you have any history of seizures or epilepsy?
*
Yes
No
Do you have metal implants or a pacemaker?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Do you sunbathe or use tanning beds?
*
Yes
No
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Rate your stress level on a scale of 1 to 10
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Your Skin
What are your specific concerns / challenges with your skin?
*
How do you feel about the quality of your skin?
*
Bad
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Bad, 10 is Fantastic
What skincare line(s) are you currently using?
*
What skin care products are you currently using on your face? Please check all that apply.
*
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
None
Other
Have you ever had facial treatments, chemical peels, microdermabrasions, or any resurfacing treatments?
*
Yes
No
If yes, when?
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
*
Yes
No
If yes, in the last month?
Are you currently using any products that contain the following ingredients?
*
Glycolic acid
Lactic acid
Exfoliating scrubs
Hydroxy acid products
Vitamin A derivatives (ie., Retinol)
None
Have you ever experienced the following conditions on your skin?
*
Flakiness
Tightness
Obvious dryness
None
Do you use an SPF daily?
*
If not, why?
Do you burn easily in moderate sunlight?
*
Yes
No
Do you suffer from sinus problems?
*
Yes
No
Do you ever experience burning, itching or stinging sensations on your skin?
*
Yes
No
Do you have a tendency to redness?
*
Yes
No
Are you taking any form of birth control?
*
Yes
No
N/A
Are you pregnant?
*
Yes
No
N/A
Trying to get pregnant?
*
Yes
No
N/A
Are you currently on any hormone therapy?
*
Yes
No
Is there anything else you would like me to know for your appointment?
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
*
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