Confidential Skincare Intake

Confidential Skincare Intake
Welcome to Graceful Escapes and thank you for choosing me for your skincare! To ensure the safest and most effective treatment possible, please complete this confidential intake form before your first visit, or anytime your health or skincare routine changes.

I know this form is detailed, but every question helps me customize your treatment with care. Medications, skincare products, supplements, and lifestyle factors can all affect your skin’s health and how it responds to treatment. Having accurate, up-to-date information allows me to make the best choices for your skin's safety and results.

If you’re unsure about a question or prefer to talk in person, just let me know in the space provided, I’m happy to discuss it with you.

Your information will always be kept private and secure.

You’re welcome to update this form anytime things change.

Let’s get started!

Please provide your contact details and a little background so I can tailor to your experience.
Name*

First NameLast Name
Email
example@example.com
Phone Number*

Area CodePhone Number
Preferred Contact Method: (Phone/Text/Email)
Birthday
Example: 9/22/2019
How did you hear about me?*
(Referral, Google, Facebook)
Skin History & Current Routine

Understanding your skin's unique needs helps me give you the best care possible. Please answer as fully as you can-and feel free to write "not sure" or "prefer to discuss" if that feels better for any question.
Have you ever had a facial treatment before?
If yes, when was your last facial?
What has been bothering you most about your skin in the last 30 days?
Please select all that apply to your skin.

Rough TextureBumpsDry SkinDull SkinBrown SpotsAcne BreakoutFine LinesHyper pigmentationSensitive SkinClogged PoresAcne ScarsWrinklesSensitive SkinItchy/ Burning SkinIrritated SkinSkin ReactionsOther
What are your top skincare goals right now?
Please list the skincare products you're currently using- or your typical routine. (cleanser, toner, moisturizer, SPF, serums, masks, etc.)
Are you currently using any of the following exfoliating skincare products?*

Retinoids (prescription or over the counter like Retin-A, Differin, Tretinoin)Acids (AHA, BHA, glycolic, salicylic, lactic, etc.)Benzoyl peroxideHydroquinone (Lightening Agent)ScrubsNoOther
If yes, how often?
Have you experienced any recent skin reactions or sensitivities?
(Include anything that caused redness, stinging, burning, or discomfort)
Do you have any regular cosmetic procedures (Botox, fillers, microneedling, peels, laser, waxing, etc.)?
(If yes, please include the date of your most recent treatment.)
Do you tan or use tanning beds?
(If yes, how often?)
Anything else you would like me to know about your skin or your goals?
Medical History & Wellness

Your skim is connected to your overall health. Please let me know if any of the following apply. This ensures I choose the safest products and techniques for you.
Do you have any of the following? (Check all that apply.)*

DiabetesHeart conditionHigh/Low blood pressureSeizure disorderAutoimmune conditionSkin cancerPCOSHormonal disorderThyroid disorderNone of the aboveOther
Are you currently under a doctor's care for any medical condition?*

YesNoOther
Do you take any medications (oral or topical)? (Yes/No- If yes please list or type "prefer to discuss")*
This includes prescriptions, birth control, acne meds, and anything that might affect your skin.
Do you take supplements or vitamins regularly?(Yes/No- If yes please list or type "prefer to discuss")
Do you have any allergies? (including skincare, latex, ingredients, medications, nuts, fruits)*
Yes/No- If yes please list
Are you pregnant or trying to become pregnant? (Yes/No- Not Applicable)*
Do you have any injuries, disabilities, areas of trauma or areas of sensitivity that I should be aware of or avoid touching in order to keep you safe and comfortable? If yes, please explain:*

What is your overall stress level?

	1	2	3	4	5

1 is Very Low, 5 is Super High

Consent, Policies & Final Notes

Thank you so much for taking the time to complete this form-your honesty and openness help me give you the best, safest care possible. Before we wrap up, please review the following policies.

Scheduling & Communication

Appointments require completed intake forms prior to your first visit. If anything changes with your health or skincare routine, please update this form or let me know before your next appointment. Open communication helps prevent unwanted reactions and ensures your treatment is always taliored to your needs.

Health & Safety Disclaimer:

I understand that skincare treatments carry certian inherent risks. I agree to disclose all relevant health and skin information to the best of my knowledge. I understand that not sharing important information (such as medications or recent procedures) may result in an adverse reaction or less effective treatment.

Privacy

All information provided is confidential and used solely for the purpose of creating a customized, safe treatment plan.

By signing below, you awknowledge:
- You have answered the form to the best of your ability.
- You consent to treatment by Graceful Escapes based on the information provided.
- You will inform Miranda of any changes to your health, skin, or routine going forward.
Signature*

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Confidential Skincare Intake

Skin History & Current Routine

Medical History & Wellness