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Book A Service with your love this month to enter raffle (Value Over $300)
Skin Supreme
Intake Form
First Name
Last Name
Email
Phone
Have you ever had a facial?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you breast feeding?
Yes
No
Do you smoke?
Yes
No
Select your Skin Type and Concerns:
Normal
Dry
Oily
Acne
Dehydrated
Fine Line
Hypo/Hyper Pigmentation
Comedones(Blackheads)
Mills (Whiteheads)
Broken Capillaries
Scare
Wrinkles
Other
Please select your Skin Conditions:
Rosacea
Cold Sores
Eczema
Psoriasis
Warts
Dermatitis
Recent Radiation or Chemotherapy Treatment
Hives
Other
Do you have any of the following health conditions?
Aids/HIV
Cancer
Diabetes
Lupus
Heart Problems
Hepatitis
High/Low Blood Pressure
Recent Surgeries
Stroke
None of the above
Please list any other health concerns not listed.
Are you taking any medications prescribed by the doctor.
Do you take any of the following?
Retin A/Renova
Glycolic Acid/Alpha Hydroxy Acid
Accutane
Topical Vitamin C
Hydroquinone
Birth Control
Sun Screen
Please list any products you are using a cleanser, toner, serums, and moisturizers.
Have you ever had a wax?
Yes
No
Have you ever had a massage before?
Yes
No
How many ounces of water do u consume in a day?
Do you have any allergies please list them below:
Have you ever had a chemical peel?
Yes
No
If so, when was the last peel?
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