Constance Glow Facial Intake Form

Facial Treatment & Skin Consultation Form

Healthy Skin Begins With Understanding Your Skin. Please complete this form prior to your facial treatment. Your responses help us understand your skin concerns, lifestyle, medical history, and current skincare routine so we can customize your treatment safely and effectively.
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number
Format: (000) 000-0000.
This is my:
E-mail
example@example.com
Occupation
Medications
Allergies
Client History
List daily routie: cleanser, toner, moisturizer, and prescription medicine for skin
List specialty products: Mask, exfoliatior, clearasonic brush
Where are your breakouts? Face or back. Forehead, cheeks, chin, etc.
Do you pop, pick or squeeze your pimples?
Are you using a daily facial scrub?
Are you currently under stress?
Do you suffer from one of the follwing:
Do you consume the following:

Other
What is your favorite food and snack?
Have you ever had a facial before?
Have you ever incorporated Ayurveda into your life?
Are you undergoing the follwing: Microdermabrasion, Chemical Peels, Retin-A treatments?
How many glasses of water do you consume daily?
How many times per day do you have a bowel movement?
How many meals do you eat per day? Do you skip meals?
What are your skin care goals?
List any other concerns that you would like to address
All information is held in the strictest confidence. At no point is information disclosed or shared without the client’s written consent.
Should be Empty:

Facial Treatment & Skin Consultation Form