CLIENT INTAKE FORM
Date: ______________
Name:________________________________________
Email:________________________________________
Phone (where we can reach you to confirm):  ________________________
Date of Birth_________________________________    Age: _____________

	Skin Information
What products are you currently using on your face?
     Morning: Cleanser-____________________________    Night: Cleanser-____________________________
	          Toner-    ____________________________               Toner-    ____________________________
	          Moisturizer-_________________________                Moisturizer-__________________________
	          Sun block- SPF# _____________________                other-     ____________________________
	          Other-    ____________________________

Do you sunbathe or use tanning beds?   Y       N
When you sunbathe or get accidental sun, how does you skin respond? 
	 Always burn, never tan		 Burn first, tan average		 Sometimes burn, tan well
	 Occasionally burn, tan easily	 Rarely burn, tan very easily	 Never burn, always tan

How much water do you drink a day?       Little	 Average (64 oz)	 A lot (1 gal)
How much caffeine do you drink a day?  None	Little		 Average	 A lot
Do you smoke?     Y      N
Check any conditions your skin may experience throughout the day:
	 Oily all over face	    Shiny T-Zone	 Tightness	     Flakiness	        Redness
Has your skin ever reacted to products during a facial? Y    N
Does your face turn red easily?  Y    N
Primary concerns of your skin: ________________________________________________________________

	Medical Information

Check next to any conditions for which you have been treated or you are currently treating:
 Acne	  Skin Pigmentation	 Rosacea	   Cancer	    Diabetes	        Pacemaker
 Epilepsy	  Thyroid		 Cold Sores	    Eczema	    Psoriasis	        Keloid Scars
 Steroids	  Hormone Replacement Therapy        Hysterectomy    High Blood Pressure
Other__________________________________
List any current medications : _________________________________________________________________
List all food and environmental allergies: ________________________________________________________  Currently Pregnant		 Currently Nursing	

Check if you have had any of the following: 
 Cosmetic Surgery  Botox   Fillers   Retin-A   Accutane  Laser Hair Removal  Permanent Make-up
 Chemical Peels	 Microdermabrasion	     Laser Resurfacing     Waxing	 Micro current

_____________________________________		_________________________________________
Client Signature                                           		            Therapist Signature
•	Please review and sign on each visit.
•	

Al information is confidential  and will be shredded after 6 months

CLIENT INTAKE UPDATE

DATE	
  CLIENT SIGNATURE		
THERAPIST