Facial Intake Form

1. Personal Information *
2. Date of Birth: *
3. Occupation: *
4. Employer:
5. Primary Physician:
6. Emergency Contact: *
7. Emergency Contact Relationship: *
8. Emergency Contact Phone: *
9. How did you hear about us? *
10. Is this your first facial? *
11. What is your main concern with your skin? *
12. Are you presently under a physician's care for your skin condition or other problem? *
13. Are you currently pregnant? *
14. Are you taking birth control pills? If yes, what type. *
15. Are you presently using (or used the past) Aziex, Differin, Renova, Retin-A, Tazarac, Glycolic or Alpha Hydroxy acids? *
16. Are you now or have ever used Accutane? *
17. Are you taking any medications? *
18. If yes, please list name and use:
19. Do you wear contact lenses? *
20. Do you smoke?
21. Do you have any allergies to cosmetics, food or drugs? *
22. Have you ever had skin cancer? *
23. Do you often experience stress?
24. What skin care products do you use presently? *
25. Please indicate if you are affected by or have any of the following: *
26. Explain any conditions you have marked above:
27. Are there any other conditions that not listed above?
28. If yes, please explain:
I understand that the services offered are not a substitute for medical care. Any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the therapist in giving better service and is completely confidential. 

A credit card is required to reserve your appointment. We require a minimum of 24 hours notice for cancellation of any scheduled appointments and a minimum of 48 hours for cancellation of group services in order to avoid a 50% penalty of total scheduled services. Full price of your scheduled appointment will be required if no notice is given: NO EXCEPTIONS. Late arrivals may result in reduced or cancelled service.
By signing below, I agree that all the information above is true and agree to the terms. *