Comprehensive Skin Intake Form & Contact Information (HE)

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 skin, what would it be (elaborate as much as you'd like)?

Do you shave? If so, what's your shaving method (wet/dry/frequency)?

If you shave, do experience any challenges with your skin, such as razor burns or bumps?

No Yes Maybe

Which skincare brand/s and specific products do you currently use? Please provide brand name and product name. List each product in your daily or occasional routine.

What is your sunscreen routine? Do you wear sunscreen regularly? Do you reapply sunscreen throughout the day?

Are you on a specific diet?

In your assessment, what is your skin type?

If you have sensitive or reactive skin, please explain.

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.

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.

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.

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?

Please note that we do not currently accept credit cards. We look forward to welcoming you to our Skin Care Studio at 810 Walnut St in Edmonds! There is plenty of street parking available. If you have any questions, please let us know.

Comprehensive Skin Intake Form & Contact Information (HE)

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