Enhanced Skincare Intake Form
To fully enhance your skincare needs and goals, we ask you to answer honestly and fully.
Full Name *
Your answer
Date of Birth *
MM
/
DD
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YYYY
What skincare line do you currently use *
Your answer
What products do you use regularly? *
Required
What do you like about your skin? *
Your answer
What do you dislike about your skin? *
Your answer
Skincare problem areas or concerns *
Your answer
What improvements would you like to see
Your answer
Check those that apply: *
Required
Do you feel your eyes are: *
Required
Do you feel your lips are: *
Required
How does your skin feel at the end of the day: *
Required
Have you ever had an allergic reaction to any of the following *
Required
When exposed to sun, do you? *
Required
Do you have/had in the past 12 months: *
Required
Currently or in the past 10 days taken: *
Required
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it 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 Enhanced Day Spa and my skin care professional from liability and assume full responsibility thereof. *
Required
Please include these UPhancements with today’s visit: (with availability) *
Required
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