New Client Consultation Form

  • New Client Skin Health Intake

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  • How did you hear about us?*

  • Your Skin

  • What are your skin care goals?*
  • What are your skin care challenges?*
  • What would you say your skin type is?*
  • Have you ever had a facial or skin treatment before?*
  • What Skin Care Products do you currently use?*
  • Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives or Hydroquinone?*
  • Have you received any of these hair removal services in the last 30 days?*
  • Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
  • How does your skin heal?*

  • Do you bruise easily?*
  • Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

  • Your Health

  • Have you experienced any of these health conditions in the past or present?*
  • Do you?*
  • Do you take any of the following dietary / health supplements?
  • What is your sun exposure?*
  • Any known allergies?*
  • Have you used or been prescribed any medications (topical or oral) for acne / acne control?*
  • What is your alcohol consumption?*
  • Are you a smoker? *
  • Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*
  • Have you ever experienced claustrophobia? *
  • Please rate your stress level*

  • FEMALE CLIENTS

  • Are you taking birth control? *
  • Are you pregnant or trying to become pregnant?*
  • Any menopause issues? *
  • Are you undergoing any hormone replacement therapy? *

  • MALE CLIENTS

  • What is your current shaving system?*
  • Do you experience irritation from shaving?*
  • Are you undergoing any hormone replacement therapy? *
  • Should be Empty: