Skin Care Intake Form

Name *
Name
Address
Address
Phone
Phone
Have you ever experienced any of the following?
Do you smoke?
Do you wear contact lenses? *
Are you on a restricted diet?
Are you under the care of a physician or dermatologist?
Any surgeries or dental work in the past 6 months?
Any dermal injections/fillers within the last 6 month?
(a) Are you using any products that contain Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid,AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription skin products?
Have you used any of these products in the past 3 months?
Have you ever had any of the following treatments?
Have you ever had any allergic reaction to any skin products?
Do you wear sunscreen daily?
What temperature water do you cleanse your skin with?
Are you currently or trying to become pregnant?
Are you currently lactating?
Any recent changes to/from your contraceptive treatment?