Facial Intake Form Please fill the form very carefully. It’s very important to answer all questions truthfully and to the best of your knowledge. Name * First Name Last Name Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * YOUR HEALTH Within the last year, have you been under a dermatologist’s or other physician’s care? * Yes No If yes, please specify : Have you had any health problems in the past or present? * Yes No If yes, please specify : Do you have any allergies? * Yes No If yes, please specify : List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly? * Do you smoke? * Yes No Do you exercise regularly? * Yes No Do you follow a restricted diet? * Yes No Do you have metal implants, a pacemaker or body piercings? * Yes No Do you wear contact lenses? * Yes No Do you sunbathe or use tanning beds? * Yes No Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)? * Yes No Have you ever experienced claustrophobia? * Yes No Rate your stress level on a scale of 1 to 5 * 1 2 3 4 5 YOUR SKIN What are your specific concerns / challenges with your skin? * What skin care products are you currently using on your face? Please check all that apply. * Soap Cleanser Toner Serum Moisturizer Masque Exfoliator Eye Product None What skin care products are you currently using on your body? Please check all that apply. * Soap Shower Gel Scrubs Oils Hair Remover Products Self Tanners None Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments? * Yes No If yes, in the last month? Do you use Retin-A, Renova, Adapalene or any other prescription skin products? * Yes No If yes, in the last month? Are you currently using any products that contain the following ingredients? * Glycolic acid Lactic acid Exfoliating scrubs Hydroxy acid products Vitamin A derivatives(ie., Retinol) None Have you ever experienced the following conditions on your skin? * Flakiness Tightness Obvious dryness None What SPF sunscreen do you use on your face? What SPF sunscreen do you use on your body? Do you burn easily in moderate sunlight? * Yes No Do you suffer from sinus problems? * Yes No Do you ever experience burning, itching or stinging sensations on your skin? * Yes No Do you have a tendency to redness? * Yes No FEMALE CLIENTS ONLY Are you taking oral contraception? Yes No Are you Pregnant? Yes No Are you Lactating? Yes No Are you currently having or due for a menstrual cycle? Yes No MALE CLIENTS ONLY Do you have shaving challenges? Yes No If yes, please specify: QUESTIONS TO DISCUS EVERY VISIT Have you started any new medications since your last visit? Yes No Please list all other treatments you have done in last month. Waxing, Facials, Laser, Botox, Filler, etc. Which treatment, area of your face/body, when. When was your last Facial? * Phone Number * (###) ### #### Emergency Contact (###) ### #### SIGN DOCUMENT * Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. CONFIRMING Name * First Name Last Name Date of signing * MM DD YYYY Thank you!
