Facial Treatment Client Intake Form There was an error trying to submit your form. Please try again. Client Information Full Name * This field is required. Date of Birth * This field is required. Phone Number * This field is required. Email * This field is required. 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 There was an error trying to submit your form. Please try again.
