New Client Intake Form

 
Today's date *
Today's date
Name *
Name
Phone *
Phone
Address *
Address
ACNE HISTORY
For example, your acne may have started at age 13 when puberty hit or around 30 when you got pregnant.
Does anyone else in your family have acne?
Please mark yes if ANYONE in your family, even a distant relative, had acne regardless of the severity.
e.g: Accutane, Retin-a, Birth Control, Antibiotics.
e.g: Retin-a, Clindamycin, Tazorac, Azelex
e.g: Proactiv, Gluten-Free Diet, Visiting a Dermatologist
YOUR SKIN
For example, you may want your skin to be less dry, more clear, less dull, more smooth, etc.
Please indicate all of your skin care concerns. *
Please describe your skin type. *
Do you pick at your skin? *
What other services/treatments have you had performed on your face? *
Does your skin tend to scar easily? *
When you have been injured in the past, like falling and scraping your knee, do you tend to be left with scars?
Have you ever developed a keloid or other type of scar?
A keloid is a growth of extra scar tissue after injury.
PRODUCT USAGE
Please include any cleanser, toner, spf, serum, acne medication, moisturizer, eye cream, masks, etc.
Including shampoo, conditioner, hair gel, body wash, toothpaste, mouthwash, aftershave, etc.
This includes chapstick, foundation, blush, primer, lipstick, etc.
MEDICAL HISTORY
Please check if you have had any of the following conditions currently or in the past *
Please check any past or current drug/medication use. *
Are you nursing, pregnant or do you plan on becoming pregnant? *
Check if you are allergic to any of the following. *
LIFESTYLE
Do you consume any of the following on a regular basis? *
Please indicate what kind of sun protection, if any, you use on a regular basis (at least 90% of the time)? *
Do you tan or are you exposed to excessive sun (currently or in the past)? *
PERSONAL
Just a few extra questions so I can get to know you better.
We really hate charging you fees! So in order to schedule an appointment, we require that you read our cancellation policy and agree to it's terms below. Please don't ever make us enforce these :) *