Facial Treatment - Client Intake Form

  • Client Intake Form

    Facial Service

  • Your Health

    Please answer all questions truthfully and to the best of your knowledge
  • Within the last year, have you been under a dermatologist’s or other physician’s care?*
  • Have you had any health problems in the past or present?*
  • Do you have any allergies or sensitivities?*
  • Do you smoke?*
  • Do you exercise regularly?*
  • Do you follow a restricted diet?*
  • Do you have metal implants, a pacemaker, or any heart conditions?*
  • Have you ever experienced claustrophobia?*

  • Your Skin

  • What skin care products are you currently using on your face? Please check all that apply.*
  • Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?*
  • Do you use Retin-A, Renova, Adapalene or any other prescription skin products?*
  • Are you currently using any products that contain the following ingredients?*
  • Have you ever experienced the following conditions on your skin?*
  • Do  you ever experience burning, itching or stinging sensations on your skin?*
  • Do  you have a tendency to redness?*
  • Are you taking oral contraception?*
  • Are you pregnant?*
  • Are you lactating?*
  • Do you have face shaving challenges?*

  • Questions to discuss every visit

  • Have you started any new medications since your last visit?
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  • Should be Empty: