Skincare Intake Form

Skincare Intake Form
1. Personal Information *
2. Have you ever received a Facial Treatment before? *
3. How is your general health?
4. If you have any Medical Conditions, please list them:
5. If you are currently taking any prescription Medications, please list them:
6. If you are currently using any prescription skin care products or topical antibiotics/hormones, please list them:
7. If you have any allergies or skincare ingredient sensitivities, please list them:
8. Have you ever had a cold sore/fever blister?
9. Are you currently using any of these skincare products?
10. Why skin type best describes your skin?
11. Please select all skin care concerns you have
12. Please select all skin care products that you regularly use on your face
13. Do feel that you are getting enough quality sleep?
14. Do you feel like you regularly drinking enough water?
15. How often do you wear sunscreen?
16. Do you regularly do any of the following activities?
17. What is your main skincare goal that you would like to be addressed during your facial treatments?
18. Is there any other necessary information your Esthetician should know before beginning your treatment?


I understand that facials, peels, microdermabrasion, waxing, and all other skincare treatments have a risk of skin irritation, rash, burning sensation, etc. The use of organic products does not guarantee that a reaction won?t occur. All skin treatments run a risk of allergic reactions. I understand that any appointment cancellations with less than 24 hours notice are subject to a cancelation fee equal to 50% of the cost of the scheduled service.
By signing below, I agree that I have carefully read and understand all of the above and I have answered all questions fully and accurately. *