La Piel Medical & Skin History // Guest Intake Form

La Piel Medical & Skin History // Guest Intake Form

Medical & Skin History // Guest Intake Form

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Name*

First NameLast Name

Email *
La Piel will never SPAM or sell email addresses to third parties. This field is required.
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Birth Date*

MonthDayYear

Phone CallTextEmailAll

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Skin Goals and Concerns:*

Your Skin Type:*

What skin products are you currently using? *

What makeup products are you currently using? If you don't wear makeup just put none.*
YesNo

YesNo
If yes, when was the last time?

Yes (Facials)Yes (Chemical Peels)Yes (Microdermabrasion)Never
If yes, was it within the last month?

YesNo

YesNo

Do you have any allergies or sensitivities? If so please list all. *

Do you take any medications? If so, please list all medications. If you don't take any medications just put none. *
Do you take any of these medications?*

Do you have any sensitivity to light? *

How did you hear about La Piel?*

I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.*

Should be Empty: