Client Intake Form - Holistic Skin Care
Please take a few moments to fill out this form. Thank you so much for sharing this information. :) If you have already filled out this form, please only answer the first question.
Name *
Email *
Date of Birth - including year :)
1) If you have already filled out this form, has anything changed since you were last here?
2) In a sentence or two, please describe your skin. For example..is it sensitive, oily, dry, aging, acne prone, etc?
3) Please list any medications (internal or topical) that you are currently taking or have recently discontinued (past 6 months)
4) Have you ever used Retin A or Accutane? If so, when and for how long?
5) Do you have any health conditions?
6) Do you have any known skin conditions? If yes, which condition?
7) Have you had any skin care treatments in the past month (laser, microdermabrasion, fillers, botox, waxing)? If so please list treatment and approximate date of treatment?
8) Please list anything that currently bothers you about your skin:
9) Do you have any skin care "goals"?
10) Please describe your skin care routine or regimen (what you do morning, evening, weekly, monthly to your skin):
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