Client Intake Form
Facial Service
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Your Health
Please answer all questions truthfully and to the best of your knowledge.
Within the last year, have you been under dermatologist’s or other physician’s care?
Yes
No
If yes, please specify:
Have you had any health problems in the past or present?
Yes
No
If yes, please specify:
Do you have any allergies?
Yes
No
If yes, please specify:
List any medications, supplements, vitamins, diuretics, slimming pills, accutane, etc that take regularly:
Do you sunbathe or use tanning beds?
Yes
No
Rate your stress level on a scale of 1 to 5.
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Your Skin
What are your specific concerns / challenges with your skin?
What skin care products are you currently using on your face? Please check all that apply.
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
None
Other
What skin care products are you currently using on your body? Please check all that apply.
Soap
Shower gel
Scrubs
Oils
Hair remover products
Self tanners
None
Other
Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?
Yes
No
If yes, in the last month?
Do you use Retin-A, Renovate, Adapalene or any other prescription skin products?
Yes
No
If yes, in the last month?
Are you currently using any products that contain the following ingredients?
Glycolic acid
Lactic acid
Exfoliating scrubs
Hydroxy acid products
Vitamin A derivatives (ie., Retinol)
None
Have you ever experienced the following conditions on your skin?
Flakiness
Tightness
Obvious dryness
None
What SPF sunscreen do you use on your face?
Do you burn easily in moderate sunlight?
Yes
No
Do you ever experience burning, itching or stinging sensations on your skin?
Yes
No
Do you have a tendency to redness?
Yes
No
Questions to discuss every visit
Have you started any new medications since your last visit?
Yes
No
If yes, please specify:
*Confirm (to the best of my knowledges) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment
Submit
Should be Empty: