INTAKE FORM

Intake Form

Please fill out the intake form completely to help me understand your skin goals. Appointments require a submitted form. Thank you.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Date of Birth:*
How did you hear about us?*

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?

	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 no to all answers.*
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 Janny understand what your skin is use to.
Do you need any product suggestions?*
Would you like touch therapy during masking? Janny - scalp massage. Clarissa - shoulder and arms. ACNE FACIALS & ACNE PEELS DOES NOT INCLUDE THIS*

yesno

products currently using ( put "none" if does not apply) : *

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

Upload photos of skin. *

Browse Files
*Gives Janny a heads up on what treatment to perform and there are no surprises ☺️ Cancelof
ACNE PROGRAM (skip if does not apply):

If you have grade 1-2 acne and this is a skin condition you would like to work on, please fill out questions below. Please note that Janny does not provide acne treatment for grade 3-4. She reserves the right to decline appointments.
If you want to work on acne :

I want to get on the acne program - this includes coming in every 2-3 weeks for the first 2-3 months then transition to monthly . If you choose this option - please fill out the acne consent as well. Please copy and paste. https://www.skinbyjanny.com/acne-consent-formI just want to start off with a regular facial and come back when I am ready.
If you are a parent filling out for your teen, please put your name below and sign your name :)
Signature*

Clear
By signing this document, you confirm that you are aware that all necessary information can be found at https://www.skinbyjanny.com/faqs. You also acknowledge the policies regarding missed appointments, rescheduling, and cancellations, which can be found on our website.

By signing this document, you agree that "I understand that withholding information or providing misinformation may result in contraindications and irritation to the skin from the treatments received. I will cancel my appointments if any contraindications apply to me. All treatments I receive from SKIN BY JANNY, LLC are voluntary, and I release SKIN BY JANNY, LLC from liability. If anything changes on this intake form, I will email hello@skinbyjanny.com to advise."
If you currently have any of the following conditions, please refrain from booking an appointment now:

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 such as 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 such as chemical peels or microdermabrasions and dermaplanes.

1 MONTH - micro-needling, IPL

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

updated 04/2024

***VISITORS ARE NOT ALLOWED
Should be Empty:

Intake Form

ACNE PROGRAM (skip if does not apply):