Client Intake Form

Gender:

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Have you ever had facial treatment before?

Do you have any special skin problems or concerns pertaining to your face or body?

Have you ever had chemical peels, laser or microdermabrasion?

Chemical Peels

Microdermabrasion

Laser

In the last month?

Do you use Retin-A, Renova, Adapalene Hydroxil Acid or Retinol / Vitamin-A derivative products?

Retin-A

Adapalene Hydroxil Acid

In the last 3 months?

Renova

Retinol / Vitamin-A

Have you ever used any acne medication?

Have you recently used any self-tanning lotions, creams or treatments?

What areas of concern do you have regarding your skin? (Please check any that apply and explain)

Breakouts/Acne

Blackheads/Whiteheads

Excessive oil/Shine

Rosacea

Broken capillaries

Redness/Ruddiness

Sun spot/Liver spot/Brown spot

Uneven skin tone

Sun damage

Wrinkles/Fine lines

Dull/Dry skin

Flaky skin

Dehydrated

Other

What areas of concern do you have regarding your eyes? (Please check any that apply and explain)

Dehydrated

Puffiness

Wrinkles

Dark circles

Other

What areas of concern do you have regarding your lips? (Please check any that apply and explain)

Dehydrated

Cracked/Chapped lips

Other

Have you ever had an allergic reaction to any of the following?

Cosmetics

Medicine

Food

Animals

Suncreens

Iodine

AHAs

Fragrance

Shellfish

Latex

Drugs

Other

Pollen

Are you taking any oral contraceptive?

Any recent changes to or from your contraceptive treatment?

Are you pregnant or trying to get pregnant?

Any menopause problems?

Are you undergoing any hormone replacement therapy?

What is your current shaving system?

Do you experience irritation form shaving?

Ingrown hairs?

May we call you on your cellphone to confirm future appointments?

May we contact you via email about future promotions and news?

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