INTAKE FORM

If you currently have any of the following conditions, please avoid booking an appointment now.

Additionally, if you've already scheduled one, please cancel or reschedule it online.

Sunburned, extremely dry, irritated, or broken skin, such as open wounds or active cold sores, on the treatment area.

48 HOURS - Lash extensions

1 WEEK - Facial waxing and any skincare facial.

2 WEEKS - Antibiotics such as clindamycin (Cleocin-T), erythromycin (Erygel), and dapsone (Aczone). Retinoids like Retin-A (tretinoin), Avita (tretinoin), Tazorac (tazarotene), Differin (adapalene).

2 WEEKS - Botox® or any injectables. Laser hair removal or electrolysis on the face. Microblading. Advanced facials, including chemical peels, microdermabrasion, and dermaplaning.

1 MONTH - Micro-needling, IPL.

6 MONTHS - Accutane, facial lasers, cosmetic surgeries of the face, chemotherapy, or radiation.

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Date of Birth:*

How did you hear about us?*

Hello! Does the following conditions relate to you ?*

	Yes	No
Accutane or other similar meds in the past year
Are you using Benzoyl Peroxide
Chemical peels within the last month
Facial laser procedure within the last month
Cosmetic injections, fillers or implants within the last month
Recent skin lightening or bleaching agent
Eczema on the face
Psoriasis on the face
Epilepsy
Hormonal Imbalances
Breast feeding, pregnancy
Cancer or post-cancer treatments
Pacemakers or metal implants
Recent accident or serious injury:
HIV/AIDS
Hemophilia
Anemia
are you allergic to sulfur?
are you allergic to aspirin
are you allergic to latex
do you smoke
are you under a lot of stress?
women: are you pregnant or nursing?
are you claustrophobic?

Hello! Does the following conditions relate to you ?*

	Yes	No
Accutane in the past year
Are you using Benzoyl Peroxide
Chemical peels within the last month
Facial laser procedure within the last month
Cosmetic injections, fillers or implants within the last month
Recent skin lightening or bleaching agent
Eczema on the face
Psoriasis on the face
Epilepsy
Hormonal Imbalances
Cancer or post-cancer treatments
Pacemakers or metal implants
Recent accident or serious injury:
HIV/AIDS
Hemophilia
Anemia
are you allergic to sulfur?
are you allergic to aspirin
are you allergic to latex
do you smoke
are you under a lot of stress?
women: are you pregnant or nursing?
are you claustrophobic?

	Yes	No
are you allergic to sulfur
are you allergic to aspirin
are you allergic to latex
do you smoke
are you under a lot of stress?
women: are you pregnant or nursing?
are you claustrophobic?

Please explain any conditions above: put N/A if all answers are no.*

Do you have any Allergies?*

Are you on any Medications?*

What are your skin care goals?*

Ex: "I want my skin more hydrated; I want less congestions; I want my skin brighter; I want less sensitivity!"

When was your last facial and which service was it?*

*Helps us understand what your skin is use to.

Do you need any product suggestions?*

Would you like touch therapy during masking? *Excluded in all Acne Facials*

yesno

Products currently in use (put "none" if not applicable):*

	name of brand
Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Exfoliant (acids, serums, scrubs)
Acne Medications
Anything Else?
ANY acne presciptions

Upload photos of skin *

Browse Files

Photos of your skin may be required for analysis before appointments are approved. This ensures we can assess your skin properly, recommend safe treatments, and prevent unexpected outcomes. These photos are used for professional analysis only, and will never be shared without your written consent. You may cover your eyes if you prefer.

If you have grade 1-2 acne and wish to address this skin condition, please complete the questions below. Note that we do not offer acne treatment for grades 3-4 and may decline appointments.

If you want to work on acne :

I want to work on my acne - this includes coming in every 2-3 weeks for the first 2-3 months, then transitioning to monthly visits.I want to start with a regular facial and return when I am ready.

If you chose "Yes" for maintaining acne: By signing this intake form, you acknowledge that you have read and agree to the information on the specified pages.

https://www.skinbyjanny.com/acne-maintenance-guidelines

If you are a parent completing this form for your teenager, please write your name below and sign the intake form.

For clients under 18, a parent or legal guardian’s signature is required and considered legally binding.

By signing, you confirm awareness of policies on missed appointments, rescheduling, and cancellations available at:

1) https://www.skinbyjanny.com/faqs

We kindly encourage clients to PLEASE READ to ensure clarity and a smooth, informed experience.

2) https://www.skinbyjanny.com/treatment-guidelines

By signing this document, you agree that:

I understand that all skin care treatments carry risks, including possible irritation, redness, sensitivity, or allergic reactions. I confirm that I have provided complete and accurate health information and accept responsibility for notifying SKIN BY JANNY, INC. of any changes before future treatments.

I agree to release, discharge, and hold harmless SKIN BY JANNY, INC., its employees, contractors, and representatives from any and all claims, liability, damages, or expenses arising from or related to the ordinary risks of skin care treatments, provided services are performed within professional standards of practice.

This agreement does not waive rights that cannot be waived under California law.

My electronic or written signature is valid and binding.

For clients under 18, a parent or legal guardian’s signature is required and considered legally binding.

Signature*

By signing this document, you agree that: I understand that all skin care treatments carry risks, including possible irritation, redness, sensitivity, or allergic reactions. I confirm that I have provided complete and accurate health information and accept responsibility for notifying SKIN BY JANNY, INC. of any changes before future treatments. I agree to release, discharge, and hold harmless SKIN BY JANNY, INC., its employees, contractors, and representatives from any and all claims, liability, damages, or expenses arising from or related to the ordinary risks of skin care treatments, provided services are performed within professional standards of practice. This agreement does not waive rights that cannot be waived under California law.  My electronic or written signature is valid and binding. For clients under 18, a parent or legal guardian’s signature is required and considered legally binding.

VISITORS ARE NOT ALLOWED

Exceptions: An adult may accompany a teen client.

Our space is very limited. Thank you for understanding 🤎

Updated 09/2025

Intake Form

ACNE MAINTENANCE