Facial Client Intake Form

Facial Client Information
ClientName *

First Name Middle Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Client Birth Date *

Month Day Year
AGE *
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Client E-Mail *
How may we contact you? (Check all that apply)

email text message telephone
What is your family background/ethnicity? (Some skin types are more sensitive than others)
How did you hear about BodyWorks @ HealingGround?
Medical History
Are you in good health?

Yes No
Do you have a history of cold sores?
Are you taking any medication? If yes, please list medication and dosage per day
Do you have any allergies? (Latex, aspirin, shellfish, etc.) If so please list them
Do you take vitamins/herbs regularly? If so please list them.
Have you had any recent surgeries? If so please list date and type along with any complications.
Any serious illness or disease? If yes please list.
Does your diet include any of the following?

Dairy Peanuts Wheat Fruit Soy Sugar
What is your daily intake of the following (in cups)

Water Coffee Tea Soda
How often do you drink alcoholic beverages?
Do you use tobacco products

Yes No
Do you take birth control pills or hormones? If yes please list
Are you pregnant, trying to become pregnant or lactating?

Yes No
Do you now or have you ever taken Accutane? If so indicate when.
Are you using Retin-A or any topical retinoids? If so indicate when.
Skin Care History & Analysis
What best describes your skin?

Oily Dry Sensitive Combination Normal
Which of the following would you like to improve?

Acne Enlarged Pores Scarring Blackheads Wrinkles/Signs of Aging Pigmentaion issues Clogged Pores
Do you currently or have you ever used any of the following on your face?

Chemical Peels Scrubs Laser/IPL Hydroquinone Microdermabrasion Buff/Loofah Retin A (tretinoin) Glycolic acid Wax Electrolysis Benzoyl Peroxide Salicylic acid
What products and brands of skincare are you currently using?
Do you sunburn easily?

Yes No
Do you tan easily?

Yes No
Do you use a tanning bed?

Yes No
Do you have any history of skin cancer or malignancies? If so include dates and types.
What are your skincare goals?
I understand that there are certain risks associated with facial services. I hereby hold the company and its associates harmless and waive any and all liability that may arise from any services and/or products from BodyWorks. I have fully disclosed all information required on this form including allergies, medications, any health issues and previously performed services elsewhere. Enter your full legal name and the date below affirming that you have read and understand this.
Enter the message as it's shown *
Should be Empty:

Facial Client Information

Medical History

Skin Care History & Analysis