Facial Intake Fill out our form below or PRINT and bring in your intake during your visit. Please enable JavaScript in your browser to complete this form.Name *FirstLastAddressPhone Number *Email Address *Date of BirthReferralPhone BookNewspaperBrochureSignDoctorGoogleFriendOtherIf doctor, friend, or other, please name:Reason for visitPlease check if you are presently using the following:AccutaneGlycolic Acid/Alpha Hydroxy AcidHydroquinoneAny prescription strength topical i.e. steroids, Retin-A, Tazorac, Differin, etcPlease select all that apply.Which conditions do you want to improve?Hyperpigmentation (Brown Spots)Acne/Acne ScarringSun DamageEnlarged PoresFine Lines & WrinklesAge SpotsSurgical Facial ScarsPlease select all that apply.Other conditions you want to improve?Have you ever had an allergic reaction to any skin product or cosmetic?YesNoFEMALE CLIENTS, please check if:You are on hormone replacement therapyYou are presently taking birth control pillsYou are pregnant or planning to beALL CLIENTS, please check ifYou use a sunscreen/sun blockYou sunbathe or participate in outdoor activitiesYou have or ever had acneYou are using medications for acneYou have seen a dermatologist in the past yearYou are presently under a doctors careYou have had herpes (cold sores)You have been treated with Zovirax or any medications for herpesYou have epilepsy diabetes, or other auto-immune disordersYou have used Biore or snore stripsHave you had any of the following?Cosmetic SurgeryBotox InjectionsSkin CancerDermatitisKeloid ScarringLaser Resurfacing/IPLChemical PeelsHepatitisDermal FillersAre you allergic to Asprin, Iodine, Seaweed, or anything else?Do you do the following?SmokeTake nutritional supplementsDietExerciseWear contact lensesHave skin treatments and facialsHad electrolysis or waxing in the past weekHad permanent cosmeticsHow is your general health?ExcellentGoodFairPoorWhat skin care products are you currently using?What is it about your skin you would like to change?Anything else I should know?Required *I agree to give a 48-hour notice of cancellation or I will be responsible to pay the full session fee or will forfeit a session in any pre-paid package.EmailSubmit
