New Client Intake Form

First name

Last name

Pronouns

Email

Phone

Birthday

Month

Day

Year

Skin Concerns

Upload a recent picture of your face under direct light with no makeup. Files must be 25MB or less. Accepted file types: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp

Describe your skin concerns in your own words, the more detail the better!

What have you tried in the past to treat your current skin concerns? Please be as specific as possible.

Skincare Routine

Describe your morning skincare routine. Be as specific as possible.

Upload a picture of your morning skincare products. Files must be 25MB or less. Accepted file types: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp

Describe your evening skincare routine. Be as specific as possible.

Upload a picture of your evening skincare products. Files must be 25MB or less. Accepted file types: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp

Do you use any other products or tools on your face regularly? Makeup? Masks? If yes, please describe.

Upload a picture of all the other products and tools you use that are not already mentioned above. Files must be 25MB or less. Accepted file types: .bmp,.gif,.heic,.heif,.jfi,.jfif,.jpe,.jpeg,.jpg,.png,.tif,.tiff,.webp

How often do you do your full morning and evening skincare routine?

How often do you wear sunscreen?

How long have you been using this routine? Have you changed your skincare routine in the last 3 months? If yes, please describe.

Are you happy with your current skincare routine? Do you want to change anything?

Skin History

Describe your skincare history in your own words. What have you struggled with in the past? Have you ever sought help for your skin from a dermatologist, esthetician, or another skincare professional? How did it go?

Have you experienced acne in the past? If yes, please describe.

Have you used prescription skin medications in the past? For example: isotretinoin (Accutane), oral antibiotics, spironolactone, or prescription topicals. If yes, please list and include approximate dates.

Have you had professional skin treatments before? For example: hydrofacial, chemical peels, microneedling, dermaplaning, laser, IPL, or microdermabrasion.

Have you ever had a negative reaction to a skincare product or professional treatment? If yes, please describe the reaction and when it occurred.

Medical History

Have you experienced keloid scarring in areas other than a piercing?

Yes

No

Other

Are you currently taking any prescription medications? If yes, please list.

Have you taken any of the following in the past 12 months?

Are you currently using any prescription topical medications on your face? For example: tretinoin (Retin-A), adapalene, clindamycin, prescription benzoyl peroxide, hydroquinone, winlevi or other medicated creams.

Do you have any known allergies or sensitivities? Please include medications, fragrance, latex, adhesives, food allergies, etc.

Lifestyle

What do you do for work?

How much sun exposure do you typically get? For example, do you sit in front of a window, drive, or spend time outdoors? Please describe.

How often do you drink alcohol?

How often do you smoke cigarettes?

How often do you vape?

How often do you smoke weed?

How often do you NOT wash your face immediately after exercising/sweating heavily?

How often do you fly in an airplane?

Do you menstruate? Do you use hormonal birth control? Describe a typical menstral period if applicable.

Have you experienced any major life changes, illness, or hormonal shifts in the past 18 months?