CC Skin&Soul Guest Intake Form

Name*

First NameLast Name
Date of Birth:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are your main Skin Goals/Concerns?*
How would you describe your skin type?*

OilyDryCombinationSensitive
Please Select all that apply:*

Currently pregnantCurrently breastfeedingHistory of a bleeding disorderPacemakerDiabetesCurrent smoker/vaperCurrent or history of cancersCurrent or recent infectionCoagulation disorders or blood clotsNone of the above
History of seizuresHistory of vertigoHepatitis or liver diseaseAutoimmune disorderPCOSHigh/Low blood pressureThyroid disorderHistory of herpes simplex/cold soresNone of the above
What medications and/or supplements are you currently taking?*
Please list any topical, medication, or food allergies
Have you used Accutane in the past 6 months?*

yesno
Are you currently on or have you ever used Hydroquinone?*

YesNo
Are you currently on birth control? If so, what kind?*
Are you currently on Hormone Replacement Therapy? If so, what kind?*
Do you have a history of Eczema, Dermatitis, Psoriasis, or Rosacea. If so, when was the last flare? *
Any Antibiotic use in the past 30 days?*

yesno
Are you currently under the care of a Doctor for any reason?*
Have you worked with an esthetician before? If so what have you done? I.E: facials, peels, dermaplanes, microneedling, lasers, etc. If so, please estimate the most recent date of service:*
Please give a brief overview of your current skincare routine/products you use. (if you don't have one just leave blank)
Should be Empty: