Client Intake Form

  • Medical & Skin History

    Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
  • What is the best way to contact you?*
  • Are you allergic to anything?*
  • Have you been under the care of a physician, naturopathic doctor, dermatologist or any other practitioner within the past year?*
  • Have you had skin cancer?*
  • Do you have any permanent cosmetics or tattoos on the areas being treated?*
  • Have you had any of these health conditions in the past or present?
  • Do you follow a regular exercise program?*

  • Walking and drinking lots of water are encouraged as they are both benefical in gently flushing the skin of cellular waste that may be released during your treatment.

  • Do you smoke?*
  • Smoking greatly reduces healing of the skin and will effect the outcome of your treatment. It is best to avoid smoking 24 hours before and after your treatment. 
  • Do you follow a restricted diet?*
  • What is your current level of stress?
  • Do you currently use any of the following?
  • Do you currently have any rash, windburn, sensitivites or other issues on the area being treated?*
  • Do you use bleaching creams or Hydroquinone daily?*
  • Does your skin form Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
  • Have you used an acne medication? *
  • Have you had a reaction after having a facial treatment in the past?*
  • Have you ever had an ALLERGIC reaction to any of the following?
  • Female Clients
  • Are you pregnant or trying to become pregnant?
  • Do you have Mirena IUD, Copper IUD or other implanted birth control?
  • Are you taking oral birth control?
  • Are you lactating?
  • Any current menopause problems?
  • Skin Care History
  • Do you like scented or unscented products?*
  • Do you wear foundation?*
  • When washing my face:*
  • How often do you use a skin regimen?*
  • Do you feel claustrophobic during facials?*
  • Do you have an aversion to hot or cold tempuratures used on your face?*
  • What conditions would you like to improve?*
  • Preparing for your appointment

  • Please bring all of the products you currently use to your appointment, or fill them in below. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will be added. Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin.

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