Skincare Consultation Intake Form

Skincare Consultation Intake Form

Get ready for the best skin of your life...
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
What are you experience(s) are you interested in?*

Skincare Consult and Custom RegimenThe Acne Edit Bootcamp ProgramIn Office Treatments (Micro-Needling & Chemical Peels Coming Soon!)
Medical History
Are you currently, or have you previously experienced any of the following

Herpes SimplexHIV/AIDSHemophiliaEczemaThyroid ProblemsLupusPsoriasisHormone ProblemsAnemiaHepatitisHysterectomyHigh Blood PressureCancerDiabetesStaph InfectionsAutoimmuneRosaceaOther
If you are currently experiencing or being treated for any health-related condition, please describe:
Do you have any allergies? *
Please list all over-the-counter and prescription medications you are currently taking. If you are using birth control pills, shots or an IUD/implant please specify :*
Lifestyle Considerations

Please answer the following questions

Rows	Yes	No
Do you smoke/vape tobacco products?
Do you use fabric softener in your laundry?
Are you currently under a lot of stress?
Do you swim in a chlorinated pool?
Do you experience irritation on your face from shaving?
Do you work in extreme heat or cold or around chemicals?
Do you exercise on a regular basis?

Tell me about your diet - Do you consume any of the following?

Rows	Yes	How Often Per Week?
Fast Food
Processed Food
Dairy Products
Whey or Soy Protein
Peanut Butter/Peanuts
Seafood
Vitamins/Supplements
Do you follow a specific diet? If so please specify

What is your current skincare routine?

Skin Self Analysis
Which options best describe your skin type? You may select multiple choices.*

NormalCombinationOilyDry/DehydratedAcne ProneSensitive
Have you had any of the following treatments in the past year?

Botox/DysportFillerLaser TreatmentsChemical PeelMicro-NeedlingFacial WaxingOther
Tell me about your skincare concerns. You may select multiple choices.*

Fine Lines/WinklesLaxityTextureDiscoloration/Uneven Skin ToneAcneAcne ScarringDry/Flaky SkinIrritated SkinMelasmaRosaceaDark CirclesMiliaOverly OilyAging/PreventativeSensitivityOther
This consult is all about you! Is there anything else you would like me to know about you or your skin?
Thank you for taking the time to complete this intake form. I cant wait to get started on your journey to healthy, happy skin! By typing your name below you are agreeing to the following:

I have answered this form to the best of my knowledge. I understand that in order to experience the best results I must use all products as directed by my aesthetician. I understand that results may vary and sometimes products or regimens may need to be adjusted overtime. I understand I am responsible for the cost of products recomended. My aesthetician will work with me to create a custom regimen that fits my lifestyle, skincare concerns and budget to the best of her ability.
Type your name *
Date*

MonthDayYear
Date
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Lifestyle Considerations