Facial Intake & Skin Analysis Form

Facial Intake & Skin Analysis Form

Welcome! This form helps us understand your skin, health history, and goals so we can customize your facial experience. Your information is confidential and used only for treatment purposes.
Section 1: Client Info + Health History

Client Info + Health History
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
Date of Birth

MonthDayYear
Date
Are you under a doctors care?

YesNo
If yes, please explain.
Are you taking any medications?

YesNo
If yes, please explain
Allergies

YesNo
If yes, please explain.
Pregnant/Nursing

YesNo
Product Usage

Retin-A/RetinolAccutaneGlycolic AcidSalicylic AcidAHAs/BHAsNone of the above
Tanning

YesNo
Section 2: Skin Analysis + Skin Concerns

Skin Analysis + Concerns
What are your skin concerns?
Skin Description

NormalDryOilyCombinationDehydratedSensitiveAcne-proneUneven toneHyperpigmentationOther
Other: explain
Fitzpatrick Classification-

Type I – Pale white skin, always burns, never tansType II – Fair skin, burns easily, tans poorlyType III – Darker white skin, tans after initial burnType V – Brown skin, rarely burns, tans wellType VI – Dark brown or black skin, never burns, deeply pigmented
Facial Frequency

First timeOccasionallyMonthlyOther
Other: explain
Current skincare routine.
Reactions to products?

YesNo
If yes, please explain.
Section 3: Consent

Consent
I understand that results vary based on my skin and that professional products may cause mild temporary reactions (e.g., tingling, redness). I agree to notify my esthetician of discomfort at any time.
Agree *

I Agree
I consent to receive facial services from Modest Charm Beauty Lounge and confirm all information is accurate to the best of my knowledge.
Agree*

I Agree
Date

MonthDayYear
Date
Signature

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Facial Intake & Skin Analysis Form

Section 1: Client Info + Health History

Section 2: Skin Analysis + Skin Concerns

Section 3: Consent