Intake Form: Skin Care & Cosmetics

Tell Us About Yourself
In order to receive your prescription, please answer these questions for our physician:
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1. Personal Health Info
What is Your Height?*
What is Your Height?*
What Is Your Current Weight?*
What Is Your Current Weight?*
What is Your Birthdate?*

MonthDayYear
What is your age?*
What is your Race?*
What is your Birth Sex?*

1. Personal Health Info
Are You Currently using any prescription skin / cosmetic products? If yes, please list:*
On a scale of 1-10, how would you describe your skin sensitivity (10 being extremely sensitive)?*

1. Personal Health Info
On a scale of 1-10, how would you describe your sensitivity to sunlight (10 being extremely sensitive)?*
On a scale of 1-10, how easily do you sunburn? (10 being very easy)?*
Are you currently pregnant or breastfeeding?*
Do you use tobacco products?*

1. Personal Health Info
Please list all current medications you are taking:*
Please list any allergies you may have:*

2. General Info
What is Your Skin Type?*
Skin Concerns: What specific issues are you trying to address? (e.g., wrinkles, acne, dark spots, dryness)*

2. General Info
Current Skincare Routine: What products are you currently using, and how often do you apply them?*
Allergies: Are you allergic to any ingredients in skincare products? Could you describe them?*

3. Desired Cream
Are there any specific ingredients you're looking for or avoiding?*
What are your expectations from the cream? (e.g., immediate hydration, face tightening, anti-aging benefits)*

4. Medical History
Do you have any existing skin conditions, such as eczema or psoriasis? Please describe*
Are you taking any medications that might interact with skincare products?*

5. Information for Pharmacy
Address*

Street Address

Street Address Line 2

CityState

Zip Code

6. Contact Information
Full Name*

First NameLast Name
Best Email*
example@example.com
Phone Number*
Please enter a valid phone number.
What is the best way for the Doctor to reach you if they have additional questions?*
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