Intake Form
Hi there 🖤 The purpose of this intake form is for me to understand your unique skin concerns, goals, and habits, as well as other factors that can contribute to your skin health. This information is extremely helpful to me as your esthetician because it allows me to give you a truly customized experience and understand where you need help. All information is confidential. If you have any questions feel free to reach out to me at (650)670-2334. Please complete before your appointment to avoid delays. See you soon and I'm super excited to help you feel more confident in your skin 🖤 Mariana
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Birth Date
-
Month
-
Day
Year
Date
Preferred Pronouns
How did you hear about Glow & Dagger?
If referred by a family/friend, please write their name below
Medical Conditions
Do you currently have or have a history of any of the following? (Check all that apply)
*
Diabetes
Epilepsy or subject to seizures
Autoimmune condition
Cancer treatment
Thyroid disorder
Pacemaker or other implanted device
Psoriasis
Rosacea
Eczema
None of the above
Other
Do you have any allergies or sensitivities? If yes, please list them below.
*
If none, type N/A
Are you currently pregnant, breastfeeding, or trying to conceive?
*
Yes
No
If pregnant, how far along are you?
First trimester
Second trimester
Third trimester
Medications
Are you currently taking or using any of the following?
*
Accutane (current or within the past 6 months)
Isotretinoin
Tretinoin
Other prescription acne medications
Antibiotics
Steroid creams
Blood thinners
Hormonal birth control
None of the above
Recent Treatments
Have you had any of the following within the last 2 weeks? (Check all that apply)
*
Chemical peel
Waxing or threading (face)
Botox or fillers
IPL or Laser (face)
Microneedling
Excessive sun exposure/sunburn
None of the above
If yes, when did you receive the treatment?
Skin Goals + Concerns
What are your current skin concerns? (Check all that apply)
Acne/prone to breakouts
Clogged pores or blackheads
Hyperpigmentation
Dryness/flakiness
Sensitivity/redness
Fine lines/aging concerns
Uneven skin texture
Dehydration
Itchiness/tightness
Dark spots/post-acne marks
Dullness
What's your biggest skincare struggle lately?
What do you want to get out of working with an esthetician?
Current Routine/Lifestyle
Please take this quick 3 minute quiz to determine your skin type
(click here to take quiz)
. Please enter your results below.
*
Which products do you currently use regularly in your AM routine?
*
Cleanser
Toner
Retinol/retinoids
Serum
Moisturizer
Eye cream
SPF
Nothing consistently
Which products do you currently use regularly in your PM routine?
*
Cleanser
Toner
Retinol/retinoids
Serum
Moisturizer
Eye cream
Nothing consistently
Do you exfoliate regularly?
*
Yes
No
How often do you exfoliate?
*
Never
1x/week
2-3x/week
4+ times/week
Unsure
Do you wear SPF regularly?
*
Daily
Sometimes
Rarely
Never
What is your occupation?
List the products you currently use if you know them
Additional Information
Is there anything you'd like me to avoid during your treatment? (E.g., strong scents, certain massage areas, bed heating, specifc ingredients)
Is there anything else you'd like me to know?
Please take a photo of all the skincare products you’re using right now, including anything you use occasionally.
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By signing below, I acknowledge that the information I have provided is accurate and complete to the best of my knowledge. I understand that failure to disclose relevant medical or skincare information may result in adverse reactions for which Glow & Dagger Skincare cannot be held responsible.
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