Intake Form

Booking Policy

Is this your first appointment with us?

In order for me to understand your skin care needs and overall health, you must complete the form below. You only need to complete this form once. I cannot finalize your first appointment until you submit this information.

All information you submit through this form will be only used for my analysis of your skin care needs and will be kept in the strictest confidence.

Today's Date *

Your Name *

Email Address *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone *

Date Of Birth *

Your Medical History

Are you currently under the care of a physician? *YesNo

Have you experienced any of these health conditions in the past or present? *

Hormone ImbalanceCancer/ Systemic diseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesNoneOther

If you chose "Other," please explain *

Any known allergies? *

AsprinLatexFruitsShellfishLidocaneFragrance/essential oilsTree NutsDairySunscreenPollenNoneOther

If you chose "Other," please explain *

List medications/supplements you are currently taking. *

Have you ever received any botox or fillers? if so, where and when? *

Have you ever experienced claustrophobia? *YesNo

Please rate your stress level *LowHighMediumNone

Your Skin

What are your skin concerns?

What would you say your skin type is? *

NormalCombinationAcneSensitiveDryOily

What skincare products do you use on a daily basis? *Please indicate each product

Do you experience frequent breakouts? *yesno

Have you ever been diagnosed with skin cancer? *YesNo

Have you been diagnosed with eczema, psoriasis or rosacea? *yesno

Are you currently using or have used? *

AccutaneRetin-APrescribed topicalsExfoliants

Please list any products that may contain any type of exfoliants such as glycolic, lactic acid, salicylic acids, etc. *

Have you ever received microdermabrasion, chemical peels, dermaplaning, laser services, microneedling? *Yes, within last monthYes, within last 2-3 monthsNo

Do you? *

wear contact lenseshave metal implantssmokehave a pacemakertandrink alcoholwear spfconsume caffeineHave you had epilepsy or seizures, are pregnant, have known cancer tumors or metastases, on steroidal medications, or are photosensitive?

Female Clients

Are you taking birth control? *YesNo

Are you pregnant or breast feeding? *YesNo

Please indicate if there are any other concerns regarding your skin or overall health:

Consent *

By checking this box I give consent to my Aesthetician to perform microdermabrasion or chemical peels if suggested and agreed to. 

Yes, I agree with the privacy policy.

Submit