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Skin by Marywynn

New Client Intake Form

Today's Date

Appointment Date

Your Birthday

Your Name (required)

Address

City, State, Zip

Your Email (required)

Phone Number

How did you hear about Skin by Marywynn?

What is your occupation?

Do you have children?
yesno

If yes, how many and what age range?

Have you ever had a facial?
yesno

If yes, when was your last facial?

How were the results of your last facial?

Did you break out after your last facial?
yesno

What is your current stress level?

Do you have any allergies (seasonal, food, drugs, products, etc.)? Please list below
yesno

Have you ever had a bad reaction to a skin care product ? Please list below
yesno

Allergies/Reactions:

Do you have any current medical conditions?
yesno

If yes, please list.

Are you taking any prescription medications, either topical or internal, including birth control?
yesno

If yes, please list.

(Please include any Accutane, Retin-A, or Alpha Hydroxy Acid products)

Do you smoke?
yesno

If yes, how many per day?

Have you had any cosmetic surgery, Laser Treatments or injections such as Botox or Fillers?
yesno

If yes, what and when?

Describe your current skin care routine. (Fill in brands)

Cleanse?

Exfoliate?

Tone?

Sunscreen?

Moisturize?

Eye cream?

What are your goals for your skin?

Or download a Client Intake Questionnaire (pdf) suitable for print out, if you prefer.