Client Intake/Consultation
Name:____________________________________________________________________________________
Address:__________________________________________________________________________________
___________________________________________________________________________________
Telephone:_____________________________________Date of Birth:_________________________________
In case of emergency: _______________________________________________________________________
E-Mail:_________________________________________ Okay to e-mail? [] yes; [] no
Your Skin Goals and Concerns:________________________________________________________________
Your Skin Type:[] Normal/Combo
[] Oily [] Sensitive
[] Dry [] Mild Acne
[] Mature and Aging [] Moderate Acne
What skin products are you currently using?_______________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What makeup products are you currently using?____________________________________________________
__________________________________________________________________________________________
Does your job and lifestyle require that you work/play outdoors?_______________________________________
Do you wax your facial skin on a regular basis? Yes No If so, when was the last time?___________________
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments? [] Yes [] No
If yes, was it within the last month? [] Yes [] No
Are you using? Retin-A [] Yes [] No; Are you using Benzoyl Peroxide? [] Yes [] No
Tell me about any allergies or sensitiveness you have: ______________________________________________
__________________________________________________________________________________________
Have you ever experienced a reaction to any of the following? [] cosmetics; [] medicine; [] iodine (shellfish); []
latex; [] pollen; [] food or fruit; [] animals; [] fragrance; [] alpha hydroxy acids; [] sunscreens.
Tell me about any health issues you have:_________________________________________________________
__________________________________________________________________________________________
Cancer? [] Yes [] No Chemotherapy? [] Yes [] No
Circulatory issues? [] Yes [] No High blood pressure? [] Yes [] No
Arthritis? [] Yes [] No Hysterectomy? [] Yes [] No
Hormonal imbalances? [] Yes [] No Thyroid? [] Yes [] No
Diabetes? [] Yes [] No Pregnant? Or about to become pregnant? [] Yes [] No
Lactating? [] Yes [] No Recent surgeries? [] Yes [] No
Psoriasis? [] Yes [] No Eczema? [] Yes [] No
Tell me about any medications you take:__________________________________________________________
Accutane? [] Yes [] No; Antibiotics? [] Yes [] No; Birth Control? [] Yes [] No
I have read and completed this questionnaire truthfully. 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 are voluntary and I release the company and/or skin care professional from liability.
Signature:___________________________________ Date:_________________________________________
