Confidential Skin Health Form

Confidential Skin Health Evaluation

Please fill out the form below and include all necessary details. The more details the better. To secure your time slot this appointment must be paid for in full at the time of completing this form. This is only necessary for your initial visit. Please be aware that this form needs to be completed 48 hours in advance to your appointment.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

MonthDayYear
Date
Preferred name/nickname
My pronouns are....
My current gender identity is....
My sex assigned at birth is....
Email address*
example@example.com
To begin services with Fern & Dagger Co., a skin evaluation, customized homecare, and an initial treatment are required. Consultations without treatment are reserved for virtual appointments to provide flexibility and convenience. Homecare recommendations will be available for purchase at the first visit, ensuring the skin has everything needed for optimal results.*

I understand
Following the completion of the consultation, which treatments are you considering? Please refer to the main website for detailed information and pricing on available treatments. It's important to note that all treatment plans necessitate preparation with a customized home care routine. We adhere to ethical standards and will not conduct any treatments if it is deemed unethical to do so.*

Acne BootcampProcell MicrochannelingLiquid MicroneedlingDMK Enzyme TherapyI’m not sure!/open to whatever is neededJust looking for virtual skin help
What budget are you considering for your home care routine? Please note that a focused and customized regimen typically starts at $175. However with the many brands we partner with, we aim to accommodate almost any budget. Our objective is to ensure that achieving your desired results through effective home care is easily accessible for you.*

$175 - $250$250 - $350$350+I am willing to invest whatever it may be to get started on a high quality and results-driven treatment plan and homecare routine.
How did you hear about Fern & Dagger Co? Google, social media, family/friend? (Please state the persons name)
What is your current occupation?
How many hours per week?
What are you most looking to getting out of working with me? How can I help?*
Identifying your skin concerns
Please check all skin concerns you’d like help addressing:*

AcneDehydrationSensitivityRosaceaMelasmaPore sizeFlushingOily SkinFine lines + wrinklesTextureFirmnessPermanent RednessHyperpigmentationPIE / Red ScarringDrynessBlackheadsBroken CapillariesBurning/stingingItchy SkinOther
If you selected other, please explain:
Does your skin breakout?*

Almost AlwaysFrequentlyRarelyNever
In your own words please describe any issues you are having with your skin. Be as specific as possible including the location and frequency.*
When would you say these concerns began or when did you begin to notice them?*
When you have an acne lesion or a small wound, how long does it take to heal? Would you describe yourself as a slow healer?*
How do you feel your skins hydration levels are?*
Lifestyle Factors
What is the climate like where you live? Are there seasonal shifts?*
Do you feel that the seasons changing affects your skin? If so, how?*
How is your sleep? About how many hours per night do you sleep?*
Do you work or stay up through the night for any reason?*
How are your energy levels? Do they stay consistent or do you crash? *
What would you say your level of commitment to your skin is? i.e., I'll do whatever it takes and would like a well-rounded routine/I am low maintenance and on a budget so I would like a minimal routine/etc.*
How often do you wear makeup?
How are you applying your makeup? Please think about each step in your makeup routine and list which tools you use for each step.
How often do you cleanse your makeup brushes?

Please check yes or no to the following questions:

	Yes	No
Do you smoke tobacco/marijuana/vape?
Do you use a tanning booth or artificially tan via UV exposure?
Do you pick at your skin?
Do you have difficulty sleeping?
Do you wear sunscreen everyday?
Do you use fabric softener?
Are you trying to get pregnant?
Are you pregnant/breastfeeding?

Please rate your current stress levels

LowModerateHighVery High
Please rate your daily water intake

LowModerateHighVery High
Please rate your weekly time spent driving

LowModerateHighVery High
Please rate your weekly time spent outdoors

LowModerateHighVery High
Please rate your weekly alcohol intake

LowModerateHighVery High
Do you suffer from any of the following?

BloatingConstipationIndegestionDiarrheaGas
Do you feel this is related to an internal issue?
**Only applicable if acne is a concern for you** Do you regularly eat any of the following:

Dairy ProductsSushiSeaweedFast FoodPastaWhite breadKelp
**Only applicable if acne is a concern for you** What does your diet consist of? Please go in depth the best you can. A lot of the time food we deem healthy is not always great for acne.

Please list any of the products you are currently using being as specific as possible. It is important to include brand name and product name. IE: Avoid writing "Neutrogena Serum" or 'Retinol Serum". Instead write: "Neutrogena Rapid Wrinkle Repair Serum."

	Product Name
Cleaser
Toner/Essence
Serum
Moisturizer
SPF
Eye Care
Exfoliant
Mask
Body Products
Primer
Foundation
Concealer
Setting Powder/Spray
Blush
Bronzer
Shampoo
Conditioner
Hair Treatments/Masks
Leave-in Hair Products
Shaving Cream
Other

	Yes	No
Corrective Peels
Laser or IPL Treatments
Glycolic Peels
Recent Surgery
Microdermabrasion
Skin Cancer Removal/Treatment
Microneedling/Microchanneling
Dermaplaning
Dermal Fillers or Anti-Wrinkle Injections

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Confidential Skin Health Evaluation

Identifying your skin concerns

Lifestyle Factors