Intake Form

Name*

Date of birth*

Date

Address*

Telephone*

Please enter a valid phone number.

Email Address*

example@example.com

Emergency Contact*

Emergency Contact Telephone*

Please enter a valid phone number.

Do you wear contact lenses?*

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?*

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!)