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Facial Intake Form
Facial Client Intake Form
Full Name
*
Birthday
*
Month
Day
Year
Do you have any of the following conditions? (Check all that apply)
Diabetes
Epilepsy or seizures
Blood clotting disorders
Active infection (cold sores, shingles, etc.)
Keloid or hypertrophic scarring
Skin cancer or suspicious lesions
Pregnancy or breastfeeding
Do you have any allergies or sensitivities to latex, wax, rosin, fragrances or essential oils, medications, foods or skin products/ingredients?
Are you currently taking any of the following?
Accutane (or isotretinoin, within last year)
Retin-A / Retinol / Tretinoin
Antibiotics
Blood thinners
Hormone therapy / birth control
Steroids (oral or topical)
How would you describe your skin?
Normal
Dry
Oily
Combination
Sensitive
Acne-Prone
What are your primary skin concerns?
Aging / fine lines / wrinkles
Uneven tone / hyperpigmentation
Acne / breakouts
Scarring
Redness / rosacea
Texture / dullness
Other
Have you had any of the following in the past 2 weeks?
Chemical peel
Laser treatment
Any facial - waxing / threading / hair removal
Botox or filler
Are you on any blood thinners?
*
Yes
No
List any medications
*
Do you have a pacemaker?
*
Yes
No
Submit
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