• Damion Jenkins, MSN, RN

  • DAMION JENKINS, MSN, RN

    Registered Nurse with over 15 years experience
  • RN Mobile Skincare

    RN Mobile Skincare

    SKIN CARE EVALUATION

  • Instructions:

    Please complete this new client evaluation form before your appointment can be scheduled and services are rendered. This will provide Damion with the required information to make effective and safe decisions regarding treatment options to best meet your skincare needs. All information contained in this form will be securely maintained, upholding client confidentiality practices. Information in this form will only be used for treatment services, consultation and ongoing skincare management. *Clients only have to complete this intake form once - UNLESS there have been changes to the health history. Please advise Damion of any changes as they occur.

  • Personal Information

  •  -
  • What Treatments or Services are you Interested in?*

  • Do you have any of the following minor skin imperfections that you would like treated?*
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  • What is your skin complexion?*
  • What skin type do you have?*

  • Please complete the following health-related questions: 

  • Do you have any allergies?*
  • Have you seen a Dermatologist in the past year?*
  • Have you had any cosmetic or health-related skin surgeries*
  • Are you taking any of the following medications? Select all that apply:*

  • Do you use any of the following routine skincare products?

  • Cleanser*
  • Moisture Balance*
  • Serums*
  • Face Oil*
  • SPF*
  • Exfoliation or Mask Treatment (1-2x per week)*

  • Do you have any of the following health conditions: Select all that apply:

  • *
  • Are you considered to be immunocompromised? (AIDS, Cancer, on Immunosuppressive Treatment for Organ Transplant, or Autoimmune Diseases?)*
  • Are You Pregnant?*
  • Are You Breast Feeding?*
  • Do you smoke*

  • The next questions are related to tanning and/or sunbathing:

  • Have you recently vacationed or are you planning a vacation with sun exposure?*
  • Check the number that best describes your skin's response to sun exposure without SPF protection?*

  • Thank You for Completing this New Client Intake Form!

    All information contained in this form is securely stored and will remain confidential. Please look out for a follow-up email with a link to SCHEDULE Your Treatment and/or Service. If you have questions, please contact Damion via the website: www.rnmobileskincare.com - under "After Care Instructions" then "Contact Damion with Any Concerns".

  • *All clients will need to sign a consent to treatment form as well as a social media consent form upon booking services.

    Thank you! I look forward to providing you with excellent care!
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