Skin Analysis Intake Form
Please complete this form to help us assess your skin and provide the best possible recommendations.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
What is your primary reason for seeking a skin analysis?
*
Which of the following best describes your skin type?
*
Normal
Oily
Dry
Combination
Sensitive
Other
What skin concerns do you currently have? (Select all that apply)
*
Acne / Breakouts
Redness / Sensitivity
Dryness / Flakiness
Oiliness / Shine
Fine Lines / Wrinkles
Dark Spots / Hyperpigmentation
Large Pores
Other
Please rate the current condition of the following areas of your skin:
*
Rows
Hydration
Oiliness
Sensitivity
Pigmentation
Acne / Breakouts
Poor
1
2
3
4
5
Fair
6
7
8
9
10
Good
11
12
13
14
15
Very Good
16
17
18
19
20
Excellent
21
22
23
24
25
Do you have any known allergies (including to skincare products or ingredients)? If yes, please specify.
Are you currently taking any medications or under treatment for a skin condition? If yes, please list them.
What is your current skincare routine? (Please list products and frequency of use)
How often are you exposed to the sun (outdoor activities, work, etc.)?
*
Rarely
Occasionally
Frequently
Daily
Do you smoke or consume alcohol?
*
No
Yes, smoke only
Yes, alcohol only
Yes, both
Signature (Please sign to confirm the information provided is accurate and you consent to the skin analysis)
*
Submit
Submit
Should be Empty: