Teen 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)?

Do you ever experience break-outs (pimples)?

Yes No Sometimes, not that often Sometimes, very often

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.

Do you use make-up? If so, what do you typically use? And what tools do you use to apply your make-up?

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

Are you on a specific diet?

Do you wax or thread your face?

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

Are you on any doctor prescribed medication? If so, please share the name of the medication.

Please list all known 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.

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

Do you play sports or exercise? What's your favorite?

Have you been under care with a DERMATOLOGIST in the last three months? If so, may I inquire as to the purpose?

Would you like to share anything else? Feel free to ask any question here as well.

Would you prefer to have your parent present in the room during your service?

Yes No Maybe

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?

Have you ever had a facial?

Yes No

Teen Skin Intake Form & Contact Information

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