• Contact Us

    301-909-8061

    1803 Connecticut Ave. NW
    2nd Floor
    Washington DCn20009

Skin Care, Eyebrow & Eyelash Intake

CLIENT INTAKE FORM

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(Required)
Sex:(Required)
Are you pregnant or lactating?(Required)
Do you experience irritation from shaving?(Required)

HEALTH HISTORY

Cancer (skin or other)(Required)
Diabetes(Required)
Autoimmune Disease (Lupus, RA, MS etc.)(Required)
Thyroid Disease(Required)
Neck/Back Pain(Required)
Heart Problems/Blood Pressure(Required)
Allergies (please list)(Required)
Infection (virus, bacteria)(Required)
HIV/AIDS(Required)
Eye Disorders(Required)
Chronic Pain (fibromyalgia, migraine etc.)(Required)
Epilepsy(Required)
Hormone Issues (PCOS, Endometriosis, menopause)(Required)

SKIN HISTORY

Recent surgery (general) the last 6 months?(Required)
Recent surgery (cosmetic) the last 6 months?(Required)
Recent cosmetic injections (Botox, filler etc.)?(Required)
Recent hair removal? (waxing, laser electrolysis)(Required)
Are you under a doctor’s care for skin issues?(Required)
Laser treatments/IPL within the last month?(Required)
Chemical peels within the last month?(Required)
Loss of skin sensation?(Required)
Recent sunburn?(Required)

DAILY MEDICATIONS

Accutane(Required)

DAILY SKIN CARE (1x, 2x, weekly, varies)

Cleanser/Toner
Exfoliant/Scrub
Mask
Eye Cream
Moisturizer
SPF
Night Cream
Prescription
Neck Cream

LIFESTYLE

Do you sleep from 6-8 hours a night?(Required)
Do you smoke?(Required)
Do you have chronic stress?(Required)
What is your level?
Do you exercise regularly?(Required)
Do you exercise regularly?
Do you use hormone replacement therapy?(Required)
Do you use hormone replacement therapy?
Do you drink more than 7 drinks a week of alcohol?(Required)
Do you eat at least 3 servings of vegetables a day?(Required)
Is your intake of sugar more than 100 cals a day?(Required)

(Examples: soda, desserts, other processed foods)

Do you drink more than 2 cups a day of caffeine?(Required)
Do you drink 8-10 glasses of water a day?(Required)
Do you take probiotics daily?(Required)
Do you take vitamin D3 daily?(Required)
Do you take a multivitamin daily or omega oils?(Required)

Future Appointments/Contact:

May I call you at your phone number to confirm future appointments?(Required)
May I text you to confirm?(Required)
May I contact you via mail/email about future promotions and news?(Required)

Service Consent:


I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand the appointment cancellation policy. The treatments I receive here are voluntary, and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

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Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
First time clients are required to have a copy of their ID on file. If you have previously uploaded your ID you do not have to. If you are under 18 a parent or guardian must submit their identification.