First Name ________________________ LastName ______________________           

Birthday:  ___/___/____  

Address:  ___________________________City ______________, State ___ Zip__________

Home #:  _______________ Work #: ___________ Cell #:  ______________

Occupation: _____________________ Age: under 21       21-30      31-50      over 50

Email address: ______________________________Referred by:________________

Would you like to be notified via email about future promotions and news? _no _yes

Have you ever had a facial treatment before? _ No _Yes, when? _______________

Do you have allergies to any of the following (please circle)? Cosmetics, AHA’s,  medicine, food, animals, sunscreen, latex, iodine, shellfish, nuts, fragrance, pollen, other ______________________________________________________________________________

Which of the following best describes your skin type? (Please circle one type number)

            I Creamy complexion Always burns easily, never tans

            II Light Complexion Always burns, tans slightly

             III Light/Matte Complexion Burns moderately, tans gradually

            IV Matte Complexion Seldom burns, always tans well

            V Brown Complexion Rarely burns, deep tan

            VI Black Complexion Never burns, deeply pigmented

Have you ever had chemical peels, laser or microdermabrasion?_ No _Yes

            In the last month? _ No _Yes

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? _ No _Yes describe:

 Have you used any of these products in the last 3 months? _ No _Yes

What skin care products are you currently using? (List brand where known)

Soap ___________________________         Night Moisturizer_______________

Toner ___________________________        Mask_________________________

Eye Product ______________________       Cleanser ______________________

Day Moisturizer ____________________      Exfoliator_________________________

Scrubs ___________________________      Makeup products___________________

What areas of concern do you have regarding your skin: (Please check any that apply)

Breakouts/acne _                                Uneven skin tone _                 Dehydrated _ 

Blackheads/whiteheads _                   Redness/ruddiness _              Dull/dry skin _

Excessive oil/shine _                          Wrinkles/fine lines _                Flaky skin _

Sun spot/liver spot/brown spot _         Rosacea _                               Sun damage _

Broken capillaries _                            Other_________________________________

Eyes:  dehydrated _ wrinkles _ puffiness _ dark circles _ Other: ______________

Lips:   dehydrated _ cracked/chapped lips _ Other: ____________________________

What SPF do you use on your face? ____________ How often/when? _____________

Have you had any recent tanning bed or sun exposure?  _ No _Yes

Have you experienced Botox, Restylane or Collagen injections? _ No _Yes

Female Clients Only: 

Are you taking oral contraceptives? _ No _Yes

Any recent changes with your contraceptive treatment? _ No _Yes

     If so, what and when: __________________________

Are you pregnant or trying to become pregnant? _ No _Yes

Any menopause problems? _ No _Yes

Are you undergoing any hormone replacement therapy? _ No _Yes

Male Clients Only: 

What is your current shaving system? Wet shave _ Electric _

Do you experience irritation from shaving? _ No _Yes Ingrown hairs? _ No _Yes

Clients Signature_______________________________________________________