Facial Intake Form
3016 Mountain Rd ~ Glen Allen, VA 23060 ~ (804)277-4498
Name:
_______________________________________________________________________________
Home #: ______________________ Cell #:_____________________ Work
#_____________________
Address: ___________________________________________________________ Apt. #:
___________
City: _____________________________________ State: _________________ Zip:
_________________
Email:
_______________________________________________________________________________
Date of Birth: __________________________ Occupation:
_____________________________________
How did you hear about us:
_______________________________________________________________
Are you married? ______________ When is your anniversary?
____________________________________
Emergency Contact: _______________________________________ Phone #:
_____________________
Your
Skin
Yes No Do you have allergies If yes, which ones?
____________________________________
Yes No Have you had a chemical peel in the last 6 months?
Ye No Do you ever experience skin breakouts?
s
Ye No Do you every experience oily shine throughout the day?
s
Ye No Do you ever experience burning, itching sensation on your skin?
s
Ye No Have you ever experienced a reaction to any skin care products? If so
s which ones?
_______________________________________________________________________
Yes No Within the last year, have you been under a dermatologist or
other physicians care? If
so what for?
____________________________________________________________
1
Ye No Within the last 2 years, have you undergone any surgeries? If yes,
s please
specify:________________________________________________________________
__
Ye No Have you had any health problems past or present? If yes, please
s specify:
________________________________________________________________________
Yes No Do you smoke?
Ye No Do you exercise regularly?
s
Ye No Do you follow a restricted diet?
s
Ye No Do you wear contact lenses?
s
Ye No Do you have metal implants, pacemaker or body piercings?
s
Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc.
that you take regularly:
_____________________________________________________________________________________
_____________________________________________________________________________________
Rate your level of stress on a scale of 1-4 (1=low, 4 = high)
Ye No Are you pregnant or trying to become pregnant?
s
Ye No Are you taking oral contraceptives?
s
Ye No Are you lactating?
s
Ye No Do you experience irritation from shaving?
s
Ye No Do you experience ingrown hairs?
s
Ye No Are you currently having or due for your menstrual period?
s
Ye No Have you started any new medication since your last visit?
s
Ye No Have you started any new medication?
s
Ye No Do you have any special skin problems pertaining to your face or
s body? If yes, please
explain: ___________________________________________________________
What skin care products are you
currently using?
Soap Cleanser ___________________ Toner/Moisturizer
___________________________
Masque ___________________ Exfoliator__________________ Eye
Products___________________
Other ____________________________________________________________________________
2
Yes No Do you currently use Accutane, Retin A, Renova,
Adapalene or any other prescription skin
care products? If yes, please list:
___________________________________________
Yes No Are you currently using any products that contact the following
ingredients(circle all
the apply):
Glycolic Acid, Lactic Acid, Exfoliating Scrubs, Hydroxy
Acids, Vitamin A Derivatives.
Yes No Have you ever had chemical peels, microdermabrasion or any
resurfacing
treatments? If yes, how long ago?
How much water do you consume dialy?
___________________________________________________
How many alcoholic beverages do you consume weekly?
________________________________________
Ye No Do you ever experience flakiness and/or tightness?
s
Yes No Do you where SPF on your face? If so which one?
________________________________
Ye No Do you sunbathe or use tanning beds?
s
Ye No Do you burn easily in moderate sunlight?
s
Ye No Do you blush easily when nervous?
s
Yes No Do you have a tendency to redness?
Ye No Do you suffer from sinus problems?
s
What skin type do you feel you have, oily, aging, dry, combination, sensitive,
rosacea? __________________
What are your skincare goals today?
________________________________________________________
If I experience any pain or discomfort during this session, I will immediately
inform the esthetician so that the session may be adjusted to my level of comfort. I
further understand that esthetics should not be considered as a substitute for
medical examination, diagnosis, or treatment, and that I should see a physician, or
other qualified medical specialist for any mental or physical ailment that I am
aware of. I understand that licensed estheticians are not qualified to diagnose,
prescribe, or treat any physical or mental illness, and nothing that is said in the
course of the session given should be construed as such. Because esthetics should
not be performed under certain medical conditions, I affirm that I have stated all
my known medical conditions, and answered all questions honestly. I agree to
keep Scents of Serenity Organic Spa and the Esthetician updated as to any
changes in my medical profile and understand that there shall be no liability on
Scents of Serenity Organic Spa and the esthetician’s part should I fail to do so.
Esthetician Signature: ____________________________
Client Signature: Date:
________________________________ ___________________________
3
Date of Treatment__________________ Performed by__________________________________
Treatment Provided____________________________________________________________________
Questions/areas of concern discussed with client_____________________________________________
_____________________________________________________________________________________
Product purchased______________________________________________________________________
Products interested in___________________________________________________________________
Scheduled follow up phone call____________________________________________________________
Notes________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Treatment__________________ Performed by__________________________________
Treatment Provided____________________________________________________________________
Questions/areas of concern discussed with client_____________________________________________
_____________________________________________________________________________________
Product purchased______________________________________________________________________
Products interested in___________________________________________________________________
Scheduled follow up phone call____________________________________________________________
Notes________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Treatment__________________ Performed by__________________________________
Treatment Provided____________________________________________________________________
Questions/areas of concern discussed with client_____________________________________________
_____________________________________________________________________________________
Product purchased______________________________________________________________________
Products interested in___________________________________________________________________
Scheduled follow up phone call____________________________________________________________
Notes________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
