Skincare Intake Form
Name *
Your answer
Untitled Title
Address *
Your answer
Phone *
Your answer
Email *
Your answer
Occupation *
Your answer
Personal Info:
What products are you currently using? Please list! *
Your answer
What areas of concern do you have with your skin? (Check all that apply) *
Required
How would you describe your eyes? (Check all that apply) *
Required
Have you recently used any self tanning lotions, creams, or treatments? If so, what parts of your body? *
Your answer
Have you had any hair removal in the past six weeks, such as shaving, waxing, electrolysis, plucking, tweezing, stringing, depilatories, etc.? If so, what type and what part of your body? *
Your answer
Have you ever had an adverse reaction to any cosmetic products? If yes, please describe. *
Your answer
Have you ever been diagnosed with any type of skin cancer on your body? If yes, where? *
Your answer
Are you currently under a physicians care for any skin disorders such as acne, Rosacea, Eczema, Psoriasis, etc.? If so, please describe. *
Your answer
Have you had a chemical peel, laser, or microdermabrasion treatment in the last six months? *
Have you ever had Botox, Restylane, or Collagen injections? If yes, please describe. *
Your answer
Have you ever used Accutane, Adapalene, Hydroxyl acid, or Retin-A/Renova? If yes, when and why? *
Your answer
Do you take any type of medication? Please list. *
Your answer
What is your UV exposure? i.e. Outside often, working outside, laying out to tan, tanning beds, etc. *
Your answer
Do you have any allergies? *
Required
Do you smoke or vape? *
Do you have a pacemaker or any pins in bones? *
Your answer
Are you wearing contact lenses today? *
Female Clients only
If these do not apply to you, please mark N/A
Are you taking oral contraceptives? *
Have you recently changed your contraceptive treatment? If yes, please describe *
Your answer
Are you pregnant or lactating? *
Are you in menopause? *
Are you undergoing any form of hormone replacement therapy? If yes, please describe. *
Your answer
Male Clients Only
If these do not apply to you, please mark N/A
Describe your current shaving system. *
Your answer
Do you ever have irritation from shaving? *
Are you undergoing any form of hormone replacement therapy? If yes, please describe. *
Your answer
Electronic Signature Agreement
By selecting the "I Accept" button, you are signing this
Agreement electronically. You agree your electronic signature is the legal equivalent of your
manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound
by this Agreement's terms and conditions.
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and this supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments i receive here are voluntary and I release Chroma Hair Studio & Spa and/or the skincare professional from liability and assume full responsibility therof. *
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