Skincare Treatment Form
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3Skincare Treatment Form
Date: _______________________________
Name: __________________________________________________________
Date of Birth: _________________
Address: ________________________________________________________________________________________
Home Phone: __________________________________ Business Phone: __________________________________
Cell Phone: _____________________________________ E-mail address: __________________________________
Single: m No m Yes
Married: m No m Yes If yes, anniversary date: ___________________
Employer: _________________________________________ Occupation: __________________________________
Does your job require that you work outdoors?
m No m Yes
Referred by: _____________________________________________________________________________________
What would you like to achieve from your treatment today? ____________________________________________
Your Skin Care
1) Have you ever had a facial treatment before? m No m Yes, when? _________________
2) Have you ever had a body spa treatment before?
m No m Yes, when? _________________
Massage:
m No m Yes
Salt glow:
m No m Yes
Seaweed wrap:
m No m Yes
Moor mud:
m No m Yes
Body scrub:
m No m Yes
Other: ___________________________________________________
3) Which of the following best describes your skin type? (Please circle one type number)
I
Creamy complexion
Always burns easily, never tans
II
Light Complexion
Always burns, tans slightly
III
Light/Matte Complexion
Burns moderately, tans gradually
IV
Matte Complexion
Seldom burns, always tans well
V
Brown Complexion
Rarely burns, deep tan
VI
Black Complexion
Never burns, deeply pigmented
4) Do you have any special skin problems or concerns pertaining to your face or body? m Yes m No
specify: ____________________________________________________________________________________
5) Have you ever had chemical peels, laser or microdermabrasion? m No m Yes In the last month? m No m Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? m No m Yes
describe: __________________________________________________________________________________
Continued a
member
Associated Skin Care Professionals
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Parent category: Business