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New Client Intake Form

Client Intake Form

How did you hear about us?
What are your skin care challenges?
Have you ever had a facial or skin treatment before?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differer, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
Have you ever received chemical peels, laser services or microdemabrazion treatments?
Have you received any Botox, Juverderm or other dermal fillers in the last two weeks?
Have you experienced any of these health conditions in the past or present?
Please select all that applies:
Do you take any of the following dietary/health supplements?
Have you been prescribed any medication (topical or oral) for acne/acne control?
Do you currently have a skin care regimen?
Please check the products you use in your current skin care regimen
Do you smoke?
Please rate your stress level
Are you pregnant or trying to to become pregnant?
Are you currently taking birth control?

Post Facial Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 30+) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Enzyme peels, Dermaplaning, Microdermabrasion, chemical peels or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your skin. 

I consent to before and after photos release. I agree that it may be necessary to track progress of my skin.

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional and business from liability and assume full responsibility thereof. *

Thanks for submitting!

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