Alpenglow Aesthetics Intake Form
New skincare client form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth
Occupation
I was referred by?
Friend or family member
World Wide Web
Gift Certificate
Other
What brings you in today? Areas of skin concern?
What type of skin services or cosmetic procedures have you received so far?
Are you currently receiving services for skincare in town?
Please share your current AM and PM skincare routine
next question is about homecare product
What homecare products do you use? Include all products cosmeceutical or over the counter.
What is your family Heritage? Describe any relevant history.
Do you have a history of skin cancer?
Choose the skin group that best fits your skin.
Creamy complexion, always burn rarely tan, blush easy
Light complexion, always burn tan slightly
Light to matte complexion, sometime burn but will tan gradually
Matte complexion, seldom burn always tan
Brown complexion, rarely burn, tan deep
Dark complexion, rarely burn deep pigmentation
Do you have any skin conditions of concerns on face or body?
Examples, hyperpigmentation, acne, rosacea, to name a few
Do you smoke?
What is your stress level?
low, medium, high
Please check all that apply
Take vitamins and minerals
Take protein supplements
On a fat free diet
On a high protein, low carb diet
Use THC products
Use Alcohol
Exercise regularly
Drink plenty of water
Drink coffee or tea daily
On a special diet such as vegan or other
Please elaborate if needed to the question above.
What medications are you currently taking examples (birth control, hormone replacement) include all oral or topical? What is it for?
Do you ever have fever blisters, cold sores or herpes?
Do you have acne or ever had acne? if so how severe?
Do you have any allergies or sensitivities?
Are you claustrophobic?
Do you have or ever had any of the following?
Diabetes
Eczema
Epilepsy
Heart disease
Pacemaker or metal implants
menopause or perimenopause
hepatitis
Do you wear contacts?
Any mental health issues I need to be aware of?
Any phobias?
Anything else I need to know? Are you under the care of a physician for skin conditions?
Submit
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