Welcome. Facial & Skincare Intake Form Name * First Name Last Name Date Of Birth * Sex Female Male NB Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Would you like to learn more about skincare products and routines? Sure! No, thank you. Are you okay with Paige taking photos that she could share for marketing purposes? OMG, of course! No, thank you. Emergency contact * Name and Phone number Referred by How did you hear about us? Have you ever had a facial treatment before? If yes, please explain What would you like to achieve from your treatment today? What is your current skin care routine? * What products are you currently using? * Rate how you feel anbout the overall quality of your skin, 1 = bad and 10 = fantastic MEDICAL HISTORY Do you have or have you had any of the following conditions? If yes, please select them: Acne Arthritis Asthma Blood disorder Cancer Diabetes Eczema Epilepsy Fever blisters Heart condition Herpes Hepatitis High blood pressure HIV/AIDS Hyper pigmentation Hypo pigmentation Hysterectomy Immune disorders Insomnia Keloid scarring Low blood pressure Lupus Metal bone pins/plates Phlebitis, blood clots Seizure disorder Skin disease/lesions Seborrhea Thyroid condition Varicose veins Warts Any other condition: Any known allergies? * List any medications you take regularly, including vitamins, herbal supplements, aspirin: Any recent surgery, including plastic surgery? If yes, explain Are you pregnant or trying to become pregnant? Yes No What is your skin type? Normal Oily Dry Combo Unsure Your exposure to the sun? Never Light Moderate Excessive When you go out into the sun, do you (check one) Aways burn (I) Usually burn (II) Sometimes burn (III) Rarely burn (IV) Very rarely burn (V) Never burn (VI) Do you smoke? No Yes How does your skin heal? Fast Slow Scars Pigments Skin Concerns * Acne Blackheads Broken Capillaries Comedones Cherry Angioma Discoloration Dryness/Dull Skin Eczema Fine lines/Wrinkles Hyper pigmentation Hypo pigmentation Milia Oily Skin Psoriasis Redness Rosacea Sensitivity Sun Damage Have you been treated for (please check) Acne Depression Skin Disease High Blood Pressure Cold Sores Diabetes Cancer Have you ever used acne medication? * If yes, when? And which Drug? Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products? * If yes, please describe Have you received Botox, Restylane, or Collagen injections in the last 6 months? * If yes, please describe 🩷 Thank you! 🩷 320 Kokanee LoopCle Elum, WA 98922 Follow forSpeical Offers!
