New Client Facial Intake Form

New Client Facial Intake Form

CONFIDENTIAL SKIN HEALTH HISTORY
PERSONAL INFORMATION
Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
FemaleMaleOtherPrefer not to say
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Your Instagram handle (if any)
FacebookInstagramOnline SearchReferral
If referred, By whom
First Time Client Consult + TreatmentFirst Time Client Consult In PersonFirst Time Client Consult Virtual
Acne TreatmentsChemical PeelsMicrochannelingHerbal NeedlingDermaplaning (as an add on)
Yes I am ready for a new home care regimen and to come in for monthly or frequent treatmentsNo I just want a new home care regimenI just want to get a facial and relax
Tell me about your skin / what you're looking to improve or achieve by coming to Belle Choses. Include any important information of skin history / if you've been struggling for a while. The more information the better, so I can come up with a curated plan for you.*
$175 - $250$250 - $350$350 +I am ready to invest whatever it may be to get started on a quality and results driven treatment plan + regimen
YesNo
If Yes please explain
YesNo
If Yes please explain
YesNo
If Yes please explain
DryOilyCombo (Dry & Oily)Combo (Normal & Oily)Combo (Normal & Dry)
BurnsTansBurns then TansNever Burns
On a scale of 1-10 how sensitive is your skin?
What is your ethnicity?
Lifestyle & Wellness
Describe the conditions of your work environment (indoor, outdoor, by a window, extreme hot or cold...)
What does your daily commute look like?
How often do you travel by plane?
If any, what are your dietary restrictions?
Approximately how much water do you drink per day?
How often do you consume alcohol?
Rate your stress level on a scale of 1 to 5

1

2

3

4

5

1 is Low, 5 is High
Wear contact lensesSmokeConsume caffeineFrequent tanning beds or sunbatheExercise regularlyExperience ClaustrophobiaNone of the above
Your Medical History

Please answer all questions truthfully and to the best of your knowledge so that we are able to have better understanding of your general health. Understanding your medical history is crucial for optimizing your skin's health thereby enabling us to accurately analyze and access your skin care needs. It helps us select the most suitable products and treatments to help you achieve your skin care goals safely and effectively.
EczemaPsoriasisRosaceaCystic AcneHigh blood pressureHormone therapyCancerCold soresDiabetesBlood clotsKeloidsHand or Foot WartsHPV Related Filiform WartsSkin Excoriation Disorder (Skin PickingSeborrheic DermatitisVitiligoLupusAddison's DiseaseParkinson's DiseaseLymphedemaHyper/HypothyroidismArthritisBlood DisorderSeizures or EpilepsyAnxietyDepressionMetal ImplantsMenopause/Post MenopauseNone of the above
YesNo
Certain treatments can cause or worsen an outbreak (e.g. chemical peels, laser, microchanneling or microneedling) Asking your doctor for an anti-viral before certain tteatments can prevent one.
List any Medications, Supplements and Vitamins that you are currently taking or take regularly?*
YesNo
If yes, please specify:*
YesNo
YesNo
YesNo
YesNo
YesNo
Your Skin
What is your morning skincare routine? (include brand name if you can and products.)
What is your nighttime skincare routine? (include brand name if you can and products.)
How often do you wear makeup and which items do you use? (foundation, concealer, powder, etc)
YesNo
How Often?
Facial Injections (Botox, Fillers)Laser ProceduresMicro-needling/Microchanneling (CIT, PRP)MicrodermabrasionDermaplaneMicrocurrentHydrodermabrasionNanochannelingRadiofrequencyUltrasoundNone
How did your skin respond to those treatments?
AccutaneHydroquinoneDifferenTazoracRetin-A, Renova, Avida, TretinoinTopical AntibioticsOral AntibioticsSalicylic AcidSpirolactoneClindamycin/Benzoyl PeroxideOtherNone
If yes, please specify and date last usage
YesNo
YesNo
Waxing/sugaringThreadingLaser/electrolysisChemical hair removalNone of the above
YesNo
Please upload 3 clear, well lit, images of each side and the front of your bare, clean face. Starting with Straight on.
Front View*

Cancelof
Left Side *

Cancelof
Right Side*

Cancelof
There are risks involved with skin treatments, though rare it may occur.

Skincare is a journey, although there may be some changes immediately following a service, it may take multiple treatments to attain full results.

Long term noticeable results involve visits every 4-6 weeks.

To support this treatment it is extremely important to follow all post-care instructions and appropriate home care products.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly an elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (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. I give consent for all future treatments

I release Belle Choses by Styja and its staff of any liability associated with any injuries and/or current and future conditions resulting from the skincare procedures or products.
I authorize and grant Belle Choses permission to take and use all photos and videos obtained during my appointment.I grant Belle Choses permission to use my photos in print, or in digital materials. My photos and videos can also be used in social media platforms such as Facebook, Twitter, Instagram, and other social media platforms.I allow Belle Choses to edit, alter, copy, or distribute the photos or videos for media advertising and marketing.I agree that these photos & video, will now belong to Belle Choses.I understand that I will not receive any monetary compensation.
Signature
Should be Empty:

New Client Facial Intake Form

PERSONAL INFORMATION

Lifestyle & Wellness

Your Medical History

Your Skin