Facial Therapy Intake Form

Complete In-Home Facial Online Intake Form

Today's Date *:

First Name *:

Last Name *:

Email:

Home Phone #:

Cell Phone #:

Work Phone #:

Street Address:

Apt #:

City:

State:

Zip:

Email *:

Date of Birth:

Occupation:

How did you hear about us?

Are you married?
YesNo

When is your anniversary?

Emergency Contact Name:

Emergency Contact Phone #:


Your Skin

Do you have allergies? If yes, which ones?
YesNo

Have you had a chemical peel in the last 6 months?
YesNo

Do you ever experience skin breakouts?
YesNo

Do you every experience oily shine throughout the day?
YesNo

Do you ever experience burning, itching sensation on your skin?
YesNo

Have you ever experienced a reaction to any skin care products? If so which ones?
YesNo

Within the last year, have you been under a dermatologist or other physicians care? If so what for?
YesNo

Within the last 2 years, have you undergone any surgeries? If yes, please specify:
YesNo

Have you had any health problems past or present? If yes, please specify:
YesNo

Do you smoke?
YesNo

Do you exercise regularly?
YesNo

Do you follow a restricted diet?
YesNo

Do you wear contact lenses?
YesNo

Do you have metal implants, pacemaker or body piercings?
YesNo

Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc. that you take regularly:

Rate your level of stress on a scale of 1-4 (1=low, 4 = high):
1234

Are you pregnant or trying to become pregnant?
YesNo

Are you taking oral contraceptives?
YesNo

Are you lactating?
YesNo

Do you experience irritation from shaving?
YesNo

Do you experience ingrown hairs?
YesNo

Are you currently having or due for your menstrual period?
YesNo

Have you started any new medication since your last visit?
YesNo

Have you started any new medication?
YesNo

Do you have any special skin problems pertaining to your face or body? If yes, please explain:
YesNo

What skin care products are you currently using?
Soap Cleanser
Toner/Moisturizer
Masque
Exfoliator
Eye Products
Other

Do you currently use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products? If yes, please list:
YesNo

Are you currently using any products that contact the following ingredients(select all the apply):
Glycolic AcidLactic AcidExfoliating ScrubsHydroxy AcidsVitamin A Derivatives

Have you ever had chemical peels, microdermabrasion or any resurfacing treatments? If yes, how long ago?
YesNo

How much water do you consume daily?

How many alcoholic beverages do you consume weekly?

Do you ever experience flakiness and/or tightness?
YesNo

Do you where SPF on your face? If so which one?
YesNo

Do you sunbathe or use tanning beds?
YesNo

Do you burn easily in moderate sunlight?
YesNo

Do you blush easily when nervous?
YesNo

Do you have a tendency to redness?
YesNo

Do you suffer from sinus problems?
YesNo

What skin type do you feel you have, oily, aging, dry, combination, sensitive, rosacea?

What are your skincare goals today?

If I experience any pain or discomfort during this session, I will immediately inform the esthetician so that the session may be adjusted to my level of comfort. I further understand that esthetics should not be considered as a substitute for medical examination, diagnosis, or treatment, and that I should see a physician, or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that licensed estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illness, and nothing that is said in the course of the session given should be construed as such. Because esthetics should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep Scents of Serenity Organic Spa and the Esthetician updated as to any changes in my medical profile and understand that there shall be no liability on Scents of Serenity Organic Spa and the esthetician’s part should I fail to do so.