Skincare Intake Form

Client Details:

Facial form
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
Birthday

MonthDayYear
Date
How did you hear about us?
Other
Friend referral:
Do you use the following:
Skincare Routine: (please be as specific as possible)
Skincare Goals:
Skin Type:
Does your job and lifestyle require that you work/play outdoors?
Do you wax your facial skin on a regular basis? (please list areas waxed and last waxed)
Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments?
Are you using any of the following:

Other
Do you have any allergies or sensitivities?
Have you ever experienced a reaction to any of the following?

Other
Do you have any of the below health issues?:
Do you take any medications?

Other
By submitting this questionnaire, I agree that I have read and completed this fully and truthfully. I understand that witholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liabilty.
Photos will be taken for your file, do you agree to allow them to be used for social media as well?
Signature
Additional Comments
Signature
Should be Empty:

Client Details: