Facial Treatment Client Intake Form
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Client Information
Full Name
*
This field is required.
Date of Birth
*
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Phone Number
*
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Email
*
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In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All information is confidential.
Facial Treatment History
Have you had a professional facial before?
*
Yes
No
This field is required.
If yes, When was your last treatment?
This field is required.
Any recent exfoliation (chemical peels, scrubs, retinol)?
*
Yes
No
This field is required.
Are you currently using any of the following?
*
Retinoids (e.g. Retin-A)
AHAs/BHAs (glycolic, salicylic acid)
Accutane or other acne medications
Prescription skincare products
None
This field is required.
Current Medical History
Are you currently under the care of a physician for any reason?
*
Yes
No
This field is required.
If yes, for what?
This field is required.
Please select any that apply:
*
Pregnant/Nursing?
Birth Control Pills
Implants of kind: dental, breast, facial
Cancer (If yes): Radiation in the last three months
Diabetes
High Blood Pressure
Heart Condition
Pacemaker
Hormonal Imbalance
Thyroid Disorder
Seizure Disorders
Migraine Headaches
Glaucoma
Hepatitis
Cold Sores/ Herpes
Autoimmune Disorder/ HIV
Active Infections
Botox/Fillers
Recent surgeries/ Procedures
Allergies (including latex)
Skin conditions (e.g. eczema, rosacea, psoriasis)
None
This field is required.
Comments
Skin Profile
Skin Type:
*
Normal
Dry
Oily
Combination
Sensitive
This field is required.
Skin Concerns (check all that apply):
*
Acne
Blackheads/ Whiteheads
Dehydration
Sun damage
Large pores
Hyperpigmentation
Fine lines/ Wrinkles
Readness/ Rosacea
Uneven Texture
Melasma
This field is required.
Current Skincare Routine (products used)
*
Cleanser (liquid/ soap)
Exfoliator
Toner
Serums/ Night Creams
Bleaching/ Lightening Creams
Facial Oil(s)/ Masks
Moisturizers
Sunscreen/ Sunblock
This field is required.
Have you had any reactionto skincare products or treatments?
*
Yes
No
This field is required.
If yes, please explain:
This field is required.
Lifestyle Factors
Do you smoke?
Yes
No
Do you drink?
Socially
Occasionally
Daily
No
Do you drink any of these?
Tea
Coffee
Soda
Approximately, how many ounces?
This field is required.
Treatment Goals: What are your goals for today's facial?
This field is required.
Are there any areas you would like to avoid or focus on?
This field is required.
Submit
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