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Facial Intake Form
Please fill out the following form to the best of your ability.
First Name
Last Name
Phone
Email
Date of Birth
What would you like to achieve from your treatment today?
Have you been exposed to the sun or used a tanning bed in the last 24 hours?
*
Yes
No
Have you ever had a facial treatment before?
*
Yes
No
If yes, when?
Do you have any special skin problems or concerns pertaining to your face or body
*
Yes
No
If yes, what?
Have you ever had chemicals peels, laser treatments, or microdermabrasion?
*
Yes
No
If yes, when?
Have you used acne medication?
*
Yes
No
If yes, when and which medication?
Have you experienced Botox, Restylane, or collagen injections?
*
Yes
No
If yes, please specify
Are you currently pregnant or nursing?
*
Yes
No
Which of the following best describes your skin type? (Please check one)
*
Required
Type I Fair skin tones—Always burns, never tans
Type II Light skin tones—Burns easily, tans slightly
Type III Fair to olive skin tones—Burns moderately, tans moderately
Type IV Light brown skin tones—Burns slightly, tans easily
Type V Dark brown skin tones—Rarely burns, tans easily
Type VI Dark brown to black skin tones—Never burns, tans easily
What area of concern do you have regarding your skin? Check all that apply
*
Required
Acne breakouts
Blackheads
Uneven skin tone
Excess oil production
Dull looking skin
Dry skin
Sun spots
Do you currently take prescription medicines?
*
Yes
No
If yes, please specify all medications (including supplements)
Are you allergic or sensitive to any ingredients?
*
Yes
No
If yes, please specify
Please check all products you are currenty using
*
Required
Cleanser
Toner
Moisturizer
BHA
AHA
Retinol
Glycolic Peel
Exfoliator
Acids
Tretinoin
Acne Medication
SPF
Do you use a pace maker?
*
Yes
No
Are you on any blood thinners?
*
Yes
No
Have you ever been treated for skin cancer?
*
Yes
No
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
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