Intake Form
Name
*
Date of birth
*
/
Month
/
Day
Year
Date
Address
*
Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact
*
Emergency Contact Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you wear contact lenses?
*
Please Select
Yes
No
Do you have any skin allergies? (oils/ingredients)
Health History: Is there anything I need to know before we get started? The more I know the better your results. Please list allergies, medications, surgeries, diabetes, heart condition, metal plates, pregnant, nursing, cold sores, herpes, Retinal use or any topical products that might cause sensitivity.
*
What skin type do you most relate to?
*
Please Select
Dry
Oily
Combination
Sensitive
What are your main skincare concerns?
*
If you could wave a magic wand, how would your skin look in one month?
*
Any special requests today? (Extractions, skin soothing, skin clearing, hydration, relaxation, waxing)
What did you love about your last facial and what could you live without?
*
Anything else you want to share? (I love learning about my clients!)
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