Confidential Skincare Intake

Name *

First

Last

Date

Date of Birth

Email *

Phone

Occupation

What improvements would you like to see in your skin?

Are you under a Dermatologists care? If yes, why?

If yes, why?

Any Recent surgery?

If yes, why?

Are you on any medications?

If yes, what?

Any Allergies? (including Plant, Food, Fragrance, Medicine, Product, etc)

If yes, what?

Have you used/or had any of the following treatments within the last 30 days?

Are you experiencing any of the following today?

Do you wear contact lenses?

Do you have a pacemaker, metal plates or pins?

Are you pregnant and/or breast feeding?

Do you experience claustrophobia?

Cleanser

Toner

Serum

Moisturizer/SPF

Eye Treatment

Exfoliant

Mask

Phone

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