Client Intake Form

Medical Information - Skin Care

Are you using or have you used any of the following?

Have you ever reacted to any skincare products?

NoYes

If so, what kind of product and what was the reaction?

Have you seen a dermatologist in the past year?

NoYes

Have you ever had a facial treatment before?

YesNo

If so, when?

How is your skin during the day?

When you sunbathe or get accidental sun, how does your skin respond?

Have you ever had any of the following?

What areas of concern do you have? (Check all that apply):

Eyes:

Dehydrated/dryWrinklesPuffinessDark circles

Lips:

Dehydrated/dryChapped/cracked

What skin care products are you currently using? (List brand where known)

Cleanser:

Toner:

Serum(s):

Day Moisturizer:

Night Moisturizer/Creme:

Exfoliator/Scrub:

SPF:

Other:

Have you recently used any self-tanning products or received spray tan treatments?

YesNo

If so, what kind and when?

Have you used any of the following hair removal methods in the past 6 weeks?

ElectrolysisLaser

Have you had face or body waxing in the past week?

YesNo

What SPF do you use on your face?

How often/when?

What SPF do you use on your body?

How often/when?

Have you used a tanning bed or been sun tanning in the past 2 weeks?

YesNo

IF THIS IS YOUR FIRST TIME AT OUR SPA, PLEASE RETURN TO YOUR EMAIL TO ALSO COMPLETE THE GENERAL LIABILITY WAIVER ONCE YOUR CLIENT INTAKE HAS BEEN SUBMITTED.