Client Skincare Questionnaire

Client Skincare Intake Form

"*" indicates required fields

Name*
Birthdate*
Address*
Email*
Emergency Contact*
Who referred you?
How may we contact you? Select all that apply.*
Are you under a Physician's care? If yes, please describe below.*
Do you wear contact lenses?*
Are you pregnant or trying to become pregnant?*
Do you have skin sensitivities? If yes, please describe below.*
Have you had skin cancer?
Do you have any metal in your body? If yes, please specify below.*
Are you currently using or have you ever used any prescription acne medications or anti-aging creams? If yes, please describe below.*
Are you affected by any of the following? Check all that apply.
Which home products would you like more information on? Check all that apply.
Which other services would you like more information on? Check all that apply.
What is your current home skin care regimen, AM & PM?
Signature (your name submitted below will be considered your electronic signature)*
Date Signed*