Name
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First Name
Last Name
Phone
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(###)
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Email
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Instagram handle
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What type of facial were you wanting to receive?
When were you looking to receive a facial by?
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What are your skin goals?
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What are your current skin care challenges?
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Which option(s) best describe your skin type?
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Have you ever received a facial or skin treatment before?
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Do you/ have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic acid, Lactic acid, Mandelic acid, Retinol, or other Vitamin A derivatives?
If yes, please specify which product and when.
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Have you received any of these hair removal services in the past 30 days?
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Have you experienced any of these health conditions in the past or present?
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Any known allergies? (ex. medications, foods, cosmetics, etc.)
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Do you smoke?
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On a scale of 1 to 10, what is your current level of stress?
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Are you pregnant or nursing?
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Are you currently on birth control, hormone supplements, or medication ? If yes, please give further details.
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Daily water consumption ? (Oz.)
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How often do you consume caffeine and alcohol?
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Are you okay with photos/ videos being taken during the treatment for reasons such as progression, social media, etc. ?
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This intake form is CONFIDENTIAL.
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