Client Intake Form

Please answer the following questions so that I may have a better understanding of your general health and lifestyle, thereby enabling me to accurately analyze and assess your skin-care needs.


Todays Date *
Todays Date
Name *
Name
Birth Date *
Birth Date
Phone Number *
Phone Number
Address *
Address
Please check all areas of concern: *
Please check all that apply: *
Are you pregnant, possible pregnant or breast-feeding? *
Are you using or have you used any of the following? *
Have you ever reacted to skincare products? *
Have you seen a dermatologist in the past year? *
Skin Information
How is your skin during the day? *
Do you sunbath or use tanning beds? *
Does your face turn red easily? *
Have you been out in the sun or in a tanning bed in the past two weeks? *
Do you use sunblock daily? *
When you are in the sun for prolonged periods of time, do you? *
How much water do you consume per day? *
How much caffeine do you consume per day? *
Do you smoke? *
Have you had any of the following? *
Cancellation Policy
Skintopia encourages guests to schedule appointments in advance. Same day reservations and walk-in appointments are always welcome, based on availability. All reservations must be secured with a major credit card. To avoid missed appointments and late cancellation fees, please call at least 24 hours prior to your appointment. We understand that at times you may need to cancel or reschedule your appointment. Because services are guaranteed reservations, 50% payment is required for the following: less than 2 hours notification to cancel or reschedule appointments. No- show or missed appointments will be charged 50% of service. Arriving late will cut into the total time reserved for your service with full service charges still applied.
Merchandise Return Policy
Skintopia gladly accepts merchandise for exchange or store credit within 7 days of the initial purchase.
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. The treatments I receive here are voluntary and I release Skintopia and/or Lorrie Smith from liability and assume full responsibility thereof.
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. The treatments I receive here are voluntary and I release Skintopia and/or Lorrie Smith from liability and assume full responsibility thereof.