Facial Intake Form
Please complete this form to help us provide you with the best facial experience at Madd Glow Beauty.
Client Information
Today’s Date
*
-
Month
-
Day
Year
Date
Full Name
*
Birthday
*
-
Month
-
Day
Year
Date
Address
*
City
*
State
*
Zip
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
What is your occupation?
Have you ever had a facial?
*
Yes
No
Do you currently get regular facials?
*
Yes
No
If yes, how often do you get facials?
Medical History
Do you have any current medical conditions?
*
Yes
No
Current medical conditions - please list
Are you taking any topical or internal medications?
*
Yes
No
Topical or internal medications - please list
Have you had any cosmetic surgery/injections?
*
Yes
No
Cosmetic surgery/injections - please list
Do you smoke or vape?
*
Yes
No
Do you wear make-up?
*
Yes
No
Do you shower in the morning or evening?
*
Morning
Evening
Skin Care Routine
Cleanser - brand and frequency
Cleanser type
Milky
Foamy
Scrub - brand and frequency
Scrub type
Fine
Coarse
Toner - brand and frequency
Moisturizer - brand and frequency
Sun Block - brand and frequency
Serums - brand and frequency
Masks - brand and frequency
Eye products - brand and frequency
What are your goals for your skin?
*
Skin Concerns
Skin type
Dry
Combo
Oily
Mature
Acne
Reactive
Dehydration level
Mild
Moderate
Severe
Do you get oily during the day?
Yes
No
Do you react to products?
Yes
No
Products you react to - list
Do you have any allergies?
Yes
No
Allergies - please list
Consent & Signature
Client print name
*
Client signature
*
Submit
Submit
Should be Empty: