Microdermabrasion Client Intake Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Birthdate
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many problems do you have?
Milia
Comedones
Acne
Hypopigmentation Moles
Rosacea
Eczema/Psoriasis
Age Spots on Hand
Hyperpigmentation
Broken capillaries Warts
Other
How sensitive skin do you have?
Very Sensitive
Sensitive
Normal
How many of the following have you experienced before?
Glycolic Peels
Salicylic Peels
Microdermabrasion
TCA Peels
Medical Dermabrasion
Laser
Hair Removal
Waxing
Professional Facial Procedures
Retin-A
Accutane
Other AHAs
Other BHAs
Other
How much sun exposure do you get per day?
Too Much
Average
Slightly
Are you pregnant or lactating?
Yes
No
Do you have any allergies? If yes, please list them.
What do you expect from this treatment?
Client's Signature
Submit
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