Client Questionnaire

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What is your usual skin type?

Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for how long you used them: Antibiotics (oral), Antibiotics (topical), Accutane, Benzoyl Peroxide, Retin-A, Tazorac, Differin, Thyroid medication, Blood Thinning Meds.

MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)

Are you under a dermatologist’s or other physician’s care?

If yes, doctors name:

Are you taking any medications? If so, Please list them below.

Have you ever had any reaction to any products or anything you have put on your face?

If yes, what products?

Please check any of these you are allergic to:

List any other allergies:

Do you smoke/vape?

Do you drink energy drinks/caffeinated beverages?

Rate your stress level on a scale of 1-10

Do you use birth control pills, shots or use an IUD?

Are you pregnant or nursing?

How many oz. of water do you consume daily?

How many hours of sleep do you get per night?

PRODUCTS CURRENTLY USING - Please provide product names

What else have you done for your skin in the last 90 days? Chemical Peels? If so, what kind? Microdermabrasion? Dermabrasion? Laser Hair Removal? Laser Rejuvenation/Resurfacing? Skin Cancer Removal? Facial Waxing? Electrolysis? Please list any treatments below:

I consent to photos/videos being taken during my appointment for marketing, educational, and promotional purposes

By submitting this form, I confirm that the information provided is accurate and I consent to receiving facial services as booked.