Facial Intake Form

Phone Type*

Do you consent to the use of photo and/or video for educational and marketing purposes such as social media post? *

Do you work outdoors?

Have you ever had a facial?*

Had any of the follow treatments?

What is your skin type?*

How easily sunburned?*

Any special skin problems?*

Had any of the following?*

Ever used any of these products?*

Use(d) any acne treatments?

Select all that apply*

Ever used a self tanner of any kind?*

Which hair removal methods have you used?*

Any skin health issues historically?*

How are you eyes? Check all that apply...*

Any allergic reactions to the following?*

Are you currently undergoing treatment for cancer?*

Received any of the following treatments?*

Taking any oral contraceptives?

Any recent changes to your contraceptives?*

Are you pregnant, or trying to be?

Are you lactating?*

Any menopause issues?*

Any hormone replacement therapy?*

What is your current shaving system?*

Ingrown hairs?*

May I contact you to confirm appointments?*