Client Intake & Photo Upload

Client Intake Form

Share your skincare history, goals, and pre-visit photos to support a preliminary skin assessment.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Appointment Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
Date
How did you hear about Seek Skin Glow?
What are your top skin goals and concerns?
Which of the following best describes your skin type?
How does your skin typically feel after cleansing?

Other
Are you currently experiencing any of the following skin concerns?

Other
Do you experience breakouts?
Have you used any of the following within the last six months?

Other
Have you received any of the following within the last 30 days?

Other
Have you recently experienced:

Other
Are you currently taking any medications or supplements?
If yes, please list ALL medications:
Please list any allergies (including skincare ingredients, latex, or medications):
If not applicable , Type " N/A"
Do you have any of the following conditions? (Select all that apply)

Other
Are you currently under the care of a dermatologist or physician for your skin?
If yes, please provide details:
Do you wear sunscreen daily?
How often do you exfoliate?

Other
How many glasses of water do you drink daily?
How would you rate your stress levels?
Describe your current skincare routine (products, frequency, etc.):
Please list all products you are currently using .
Have you had any facial treatments in the last 3 months?
If yes, please specify type of treatment(s):
What are you hoping to achieve from today's treatment:
Please upload clear photos of your face (front and both sides) for skin analysis:

Please Upload a picture with no makeup on , thank you !
Cancelof
Is there anything else you would like your esthetician to know before your appointment?
Mobile Appointment Requirements
I have read and understand the above mobile appointment requirements.
Client Certification
Signature
Should be Empty:

Client Intake Form

Mobile Appointment Requirements