Facial Intake Form Page 2
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2Your Skin
19. Which of the following are you currently experiencing?
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Skin Cancer
Dermatitis
Keloid Scarring
Acne
Rosacea
Broken Capillaries
Treatment Reactions
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Hypo-pigmentations
Hyper-pigmentation
20. What are conditions are you wanting to improve?
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Acne/ Breakouts
Facial Scarring
Hyper-pigmentation
Hypo-pigmentations
Enlarged pores
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Fine lines and wrinkles
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21. Do you burn easily?
yes
no
22. Do you use sun screen when outdoors?
yes
no
Female Clients Only
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23. Are you taking oral contraceptives?
yes
no 25. Are you lactating?
yes
no
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24. Are you pregnant or trying to become pregnant?
yes
no
Male Clients Only
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26. What is your current shaving system?
electric
wet shave
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27. Do you experience irritation from shaving?
yes
no
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28. Do you experience ingrown hairs?
yes
no
Client or Parent Signature: ____________________________________________________ Date: __________________
Skin Care Therapist: _________________________________________________________ Date: __________________
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have
not withheld any information that may be relevant to my treatment.
1.Client Signature:
Date: ______ 2.Client Signature: ______________________ Date: ______
3.Client Signature: _____________________ Date: ______ 4.Client Signature: ______________________ Date: ______
5.Client Signature: _____________________ Date: ______ 6.Client Signature: ______________________ Date: ______
7.Client Signature: _____________________ Date: ______ 8.Client Signature: ______________________ Date: ______
9.Client Signature: _____________________ Date: ______10.Client Signature: ______________________ Date: ______
This consultation card is to correctly evaluate your special skin care needs. This information is
confidential and may be disclosed only to staff members, risk or quality personnel to assess the quality
of care and will not be passed on to a third party
.
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