Facial Treatment - Client Intake Form

Tampa Bay Skin Client Intake Form

Facial Service
Name

First NameLast Name
Date of Birth

MonthDayYear
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 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? Do you have any skin conditions we should be aware of?
If yes, please specify:
Do you have any allergies?
If yes, please specify:
Do you smoke?
Do you sunbathe or use tanning beds?
Your Skin
What are your specific concerns / challenges with your skin?
Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?
If yes, in the last month?
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
If yes, in the last month?
Are you currently using any products that contain the following ingredients?
Do you burn easily in moderate sunlight?
Do you ever experience burning, itching or stinging sensations on your skin?
Do you have a tendency to redness?
Female Clients
Are you pregnant?
Are you lactating?
Questions to discuss every visit
Have you started any new medications since your last visit?
If yes, please specify:
How did you find Tampa Bay Skin?
*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.
Should be Empty:

Tampa Bay Skin Client Intake Form

Your Health

Your Skin

Female Clients

Questions to discuss every visit