Facial & Skin Treatments Intake Form
Full Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Were you referred by someone? If yes, provide full name
First Name
Last Name
What are your main skin concern(s)? Select all that apply.
*
Dullness
Excessive Sebum Production
Dryness / Flakiness
Aging: Fine Lines / Wrinkles
Hyperpigmentation
Uneven Skin Tone
Loss of interest
Dehydration
Texture / Large Pores
Sensitivity
Dark Spots
Redness
Fatigue
Acne / Breakouts
Other
Service(s) booked, and/or interested booking in the future:
*
Signature Custom Facial (Essence, Purity, Luminesse, Eternal)
Advanced Skin Treatments (Dermaplaning, Chemical Peel, Hydradermabrasion, Micordermabrasion)
Nano (Needling) Infusion
Microneedling
What are your goals hoping to achieve through the facials & skin treatments?
*
What is your skincare routine currently? (am & pm) (brand & product names)
*
Are you willing to adjust your skin care if necessary?
Yes
No, I’ll do my own research
If yes, what is your budget for skincare products? $$$
*
Skin Health & History
Do you currently use:
*
Retinoids (retinol, tretinoin, adapalene)
AHAs (glycolic, mandelic, lactic)
BHAs (salicylic)
Benzoyl Peroxide
None of the above
Other
Have you ever had any laser or peel treatments in the treatment area(s)? If yes, list on others: what kind and when was your last session:
*
Have you gotten any Botox, fillers, or other dermal injections in the past 14 days? If yes, please list what kind & when was your last session:
*
Have you had any negative reactions to facials or skincare products before? If yes, please describe. If no, put N/A.
*
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Medical History
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Check the conditions that apply to you:
*
Diabetes
Heart Condition
High/Low Blood Pressure
Epilepsy or Seizures
Autoimmune Disease
Bleeding Disorders
Skin Conditions (eczema, proriasis, dermatitis)
Menopausal
Gold Therapy or Vita A Injections
History of Cold Sores
History of Blood Clotting
History of Keloid Scars
Migraines or Seizures triggered by light
None of the above
Other
Do you have any of the following:
*
Gold Therapy or Vita A Injections
Sun Sensitivity
Currently ongoing Cancer or Chemotherapy
Electrical Devices or Pacemaker
Metal Dental Work
Migraines or Seizures triggered by light
Recent Facial Surgery (in the last 6 months
Currently ongoing Cancer or Chemotherapy
Open Wounds or Broken Capillaries
Pacemakers
None of the above
Other
Please list any oral medication(s) you are currently taking if any:
*
Please list any topical medication(s) you are currently using if any:
*
Do you have any allergies?
*
Yes
No
If yes, please describe below:
*
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Pre-Treatment Acknowledgment:
Please check all boxes if you understand the treatment:
*
I understand certain treatments may not be performed if contraindications exist.
I will inform RHE Studio of any changes to my health or medications before my appointment.
I will follow pre-treatment guidelines provided (avoiding retinoids, AHAs/BHAs, and exfoliants as instructed).
I have read and understand the above pre-treatment acknowledgment.
Consent to Treatment:
Please check all boxes if you acknowledge:
*
I understand that facial treatments at RHE Studio are non-medical and elective.
Possible side effects include temporary redness, irritation, or mild discomfort.
My esthetician will adjust the treatment to suit my individual needs.
I have had the opportunity to ask questions and all have been answered to my satisfaction.
I give my informed consent to receive facial treatments at RHE Studio.
Photo & Video Consent:
*
Yes - personal chart only
Yes - marketing/social media (face visible)
Yes - marketing/social media (face NOT visible)
No
Signature
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Pre & Post Care Acknowledgement:
FACIAL / SKIN TREATMENT PRE-CARE CHECKLIST
*
Avoid active skincare (retinol, tretinoin, AHA/BHA, nemzoyl peroxide) for 3-5 days.
No chemical peels, microneedling, or affressive exfoliation for 7 days.
Avoid sun exposure & tanning for 3-7 days.
Pause waxing, threading, or laser in the treatment area for 7 days.
Do not pick, peel, or extract breakouts.
Arrive with clean skin (no make up if possible).
Avoid injectibles (Botox/Fillers) 2 weeks before.
Avoid alcohol 24 hours prior.
Please read each statements carefully.
*
Avoid heat, steam, sauna, hot yoga, or intense workouts for 24–48 hrs
No active ingredients (retinol, acids, exfoliants) for 3–5 daysoption 2
Avoid makeup for at least 24 hours (longer if advised) option 3
Do not pick, peel, or scratch the skin
Keep skin hydrated — gentle cleanser + moisturizer only
Apply SPF 30+ daily (reapply every 2–3 hrs if outdoors)
Avoid sun exposure & tanning for 5–7 days
Expect normal reactions such as: Mild redness, Light flaking, Temporary breakouts (purging)
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