Facial Intake Form Facial Intake Form Name: DOB: Address: State: Zip: Phone: Email: Emergency Contact Name & Number: Please circle your answer Are you pregnant or Nursing? YesNo Do you have diabetes? YesNo Do you have epilepsy? YesNo Do you have a cardiovascular &/or thyroid condition? YesNo Do you have trouble with wounds healing? YesNo Have you ever been diagnosed with cancer? YesNo If Yes, are you undergoing cancer treatment? YesNo Do you have any skin conditions? YesNo Do you work outdoors? YesNo Do you wear contact lenses? YesNo Do you exercise regularly? YesNo Do you use SPF on your face? YesNo Are you currently sick? YesNo Please list any other conditions, diseases or disorders: Is there any additional information you would like your provider to know? Signature: Date:
