New Guest Skin History Form

New Guest Skin History Form
Name *

First Name Last Name
Email *
example@example.com
How did you hear about me? *
What service(s) are you interested in booking? *

Signature facial Dermaplaning Dermaplaning Deluxe Express Peel 1 hour Peel
What concerns you most about the overall appearance of your skin? Check all that apply. *

Dehydrated Acne Acne scarring Age spots Melasma Blackheads Excessive facial hair Fine lines and wrinkles Oily skin Redness Under eye puffiness/Dark circles Rosacea Sagging skin Sun damage Texture Large pores Loss of lashes or brows Dull complexion Other
Are there any other concerns you would like to share with me?
How would you describe your skin? *

Dry Combination Oily
How would you describe your stress level? *

Little Moderate High Severe
History
Are you currently under the care of a Dermatologist or Physician for any ongoing health or skin concern(s)? If yes please elaborate. *
Do you have any allergies to foods, skin care ingredients or medications? If yes, please list and include your reaction. *
Are you currently on any medications topical or oral? If yes please list. *
How do you heal from a scratch, cut or acne break out? *

No scar White Brown Red
Do you have an allergy to latex? *

Yes No
Do you tan in tanning beds or booths? *

Yes No
List your level of activity. *

Very active. Somewhat active. Sedentary.
Please check all products you are currently using. *

Cleanser Toner Serum Exfoliant Moisturizer SPF Mask Eye Cream Self Tanner Make Up Concealer
Please list the names of the products you are currently using that you checked above. The more detail the better I can tailor your treatments and home care moving forward. *
Please upload three photos of your skin without makeup on. One front facing and one of each side, preferably in natural indirect light. This helps me to ensure we are booking the correct treatment, and it also is a good marker for the beginning of our skin care journey together. *

Cancel of
The answers I have provided are true and correct to the best of my knowledge. I give Kristin permission to take photos before each treatment to monitor my progress. Please sign below and click submit. I will respond within 24 hours Tuesday-Friday, I look forward to meeting you soon!

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