Client Intake Form
Facial Service
Name
First Name
Last Name
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
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13
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20
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25
26
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28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
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1983
1982
1981
1980
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1974
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1970
1969
1968
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1943
1942
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Your Health
Please answer all questions truthfully and to the best of your knowledge
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:
Check if you are allergic to:
sulfur
aspirin
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?
*
If you had used Accutane, provide the date of last time you took it.
-
Month
-
Day
Year
Date
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
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
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
Moisturizer
Masque
Exfoliator
Eye Products
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? (specify brand)
What SPF sunscreen do you use on your body? (specify brand)
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 discuss every visit
Have you started any new medications since your last visit?
Yes
No
If yes, please specify:
*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.
*
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