FACIAL INTAKE FORM

First name

Last name

Email

Phone

What are your main skin concerns?

Please describe your current skin care routine?

Are there any specific goals you would like to achieve for your skin?

COVID-19 Pre-Screening

Are you currently waiting on the results of a COVID-19 test?

Yes

No

Have you experienced any of the following symptoms in the past 48 hours:

Have you had any signs of a fever in the past 24 hours or had a temperature that has elevated 100.0F or greater?

Yes

No

Within the past 14 days, have you been in close physical contact with anyone who test positive with cov-19?

Yes

No

This is required, this is for your protection and mine.

ID