Corrective Facials & Express Glow Facial Intake Form

Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
What are your specific skincare concerns?*

Dry Flakey SkinBreakoutsWrinklesBlackheadsAcneLoss of FirmnessClogged PoresSkin TextureLarge PoresHyper-Pigmentation / Uneven Skin ToneRednessSkin SensitivityRosaceaOily SkinMiliaFine LinesNONEKeloid or Raised ScaringOther
Which products are you currently using on your face?*

Bar SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamMoisturizerSunscreenVitamin A (retinol, retinal, etc.)NONE
Are you under the care of a Dermatologist for any skin issues pertaining to your face, neck, arms, or chest area?*
Are you currently using any products that contain:

AHA (glycolic acid, lactic acid, mandelic acid, etc.)BHA (salicylic acid)Vitamin A derivative (retinol/retonids)Exfoliating scrubs
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO
Your Medical History
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNONEOther
Please list medications or supplements you are currently taking.
Any known allergies?*

AsprinLatex GlovesFruitsShellfishLidocaneFragrance/Essential oilsTree NutsDairySunscreenPollenNONEOther
Stress level?

LowAverageHighVery High
Male Clients
Describe your current shaving routine for facial hair?
Razor, Electric, Barber Shop, Dry Shave, Use of Creams or Gels
Do you have any skin issues from shaving?

IrritationFolliculitisBreakoutsNone
Female Clients
Are you taking birth control?

YESNO
Are you pregnant or breast-feeding?*

YESNO
How would you like to be contacted to discuss your skin concerns?

Video ChatPhone CallEmail
Pictures or videos of your skin may be requested by CES to track results and/or for social media education or marketing posts. Select your level of participation below:*

Yes, I agree to pictures and videos for all purposesYes, I agree to pictures only to track results but not to be sharedNo, I do not want pictures or videos taken for any reason
I agree to this information release form and I acknowledge that all information provided to Cindy Everson Skincare is correct.
Sign here: Signature
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Your Medical History

Male Clients

Female Clients