Facial Intake Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Medical Background
Please list any skin or health conditions you are experiencing;
*
Are you taking any Retin-A, or Accutane?
*
Retin-A
Accutane
None
Are you taking any oral or topical antibiotics? Please explain.
*
How often do you exercise? Please explain
*
How is your stress level?
*
Low
Medium
High
Extreme
Other
How many hours of sleep do you get a night?
*
Tell me about your water intake? How many glasses of 8oz water do you get in per day?
*
How much Caffeine do you consume per day?
*
Do you smoke?
*
Yes
No
Other
How much UV exposure do you get ?
*
Tanning Beds
Direct Sun
Traveling in car
Other
Please list any supplements, Medications, Allergies or recent surgeries?
*
Getting to know your skin:
Do you have any of the following:
*
Scaring
Hyper Pigmentation
Other
Do you suffer from any of the following: Please check all that apply:
*
Oily skin
Dry skin
Dehydrated Skin
Eczema
Blackheads
Acne
Milia
Whiteheads/Blackheads
Have you ever received any of the following treatments:
*
Facial
Lash or Brow Tint
Lash lift
Facial Waxing
Microdermabrasion
Laser hair removal
Chemical Peel
Vein Treatments
Other
Have you ever had an allergic reaction to the following:
*
Cosmetics
Medication
Food
Animals
Fragrance
Sunscreen
Latex
Have you ever received the following in the past 6 months:
*
Botox
Collagen Injections
Lip or Facial Filler Injections
Other
Submit
Should be Empty: