Comprehensive Skin Intake Form & Contact Information

Name

Phone

Birthday

House number & street

City, State & ZIP

Name emergency contact

Phone emergency contact

If there was something that you could change or improve about your FACIAL skin, what would it be (elaborate as much as you'd like)?

If there was something that you could change or improve about your BODY skin, what would it be (elaborate as much as you'd like)?

Your current homecare routine.

Please be very precise in this next section and list ALL products you use daily, weekly, monthly, occasionally. If you don't use anything in a specific field, just write no.

CLEANSER - NAME/S OF CLEANSER & BRAND/S. LIST ALL THAT YOU USE.

EXFOLIATION - DO YOU EXFOLIATE? IF SO, LIST PRODUCT NAME/S & BRAND/S. LIST ALL THAT YOU USE.

TONER - DO YOU USE A TONER? IF SO LIST NAME/S & BRAND/S.

SERUM - DO YOU USE A SERUM? IF SO, LIST NAME/S & BRAND/S. LIST ALL THAT YOU USE.

MOISTURIZER - DO YOU USE A MOISTURIZER? IF SO, LIST NAME/S & BRAND/S. LIST ALL THAT YOU USE.

MASK - DO YOU USE A MASK? IF SO, LIST NAME/S & BRAND/S.

RETINOL - DO YOU USE PRODUCTS THAT CONTAIN RETINOL? IF SO, LIST NAME/S & BRAND/S.

AHA / BHA - DO YOU USE PRODUCTS THAT CONTAIN GLYCOLIC, LACTIC ACID, SALICYLIC ACID? IF SO, PLEASE LIST NAME/S & BRAND/S.

HYDROQUINONE - DO YOU CURRENTLY USE HQ?

No Yes

SPF - DO YOU WEAR SUNSCREEN? IF SO, LIST NAME/S & BRAND/S.

DO YOU USE ANY OTHER PRODUCTS? IF SO, LIST NAME/S & BRAND/S.

Are you on a specific diet?

In your assessment, what is your skin type?

If you have sensitive or reactive skin, please explain.

Do you wax or thread your face?

Do you have any metal implants in your face or body?

Have you had any surgeries? If so, please let us know what kind of surgery. If not, just write "no"

Do you smoke or live with a smoker?

No Yes

Please list all allergies.

Do you suffer from foot fungus?

No Yes

Are you pregnant or breastfeeding?

No Yes

Are you on hormone therapy?

No Yes

Have you ever been on a drug called Accutane?

No Yes

Are you prone to cold sores? If you currently have one, please advise us immediately so we can reschedule your appointment.

No Yes Yes, but at the time of completing this form I haven't had one in more than a month

Have you had neurotoxins injections or fillers within three weeks prior to your appointment?

No Yes Yes, but at the time of completing this form I haven't had one in more than a month

If so, please list the date.

Have you had a Chemical Peel in the last 6 month?

No Yes

If so, please list the date.

Have you had Laser treatments done in the last three month?

No Yes

If so, please list the date and what type of laser.

Would you mind sharing your height and weight? Can you walk up and down stairs easily? Why do we ask? In case special accommodation is required.

Do you exercise? Feel free to elaborate the type and frequency of your routine.

Do you use tanning beds?

No Yes

How does your skin react to sun exposure?

Have you been under care with a DERMATOLOGIST, PLASTIC SURGEON, ESTHETICIAN in the last three months? Please elaborate if any applies.

Are you interested in LED light therapy?

No Yes

Would you like to share anything else?

Are you a social media superstar? If yes, what's your go-to platform?

Who may we thank you for the Referal

How did you hear about us?

What is your favorite part in a facial session?

Comprehensive Skin Intake Form & Contact Information

Your current homecare routine.

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