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Microdermabrasion
NanoStamp 360
FOR MEN
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Client Intake Form

1405 Alternate A1a,

Jupiter, FL 33469

Client Intake Form

Client Intake Form

Contact Us

First Name

New Field:

Address

Telephone

Email

Okay to e-mail?

Ye

No

Emergency Contact

Telephone

Your Skin Goals and Concerns

Your Skin Type

Normal/Combo

Oily

Sensitive

Dry

Mild Acne

Moderate Acne

Mature & Aging

What skin products are you currently using?

What makeup products are you currently using?

Does your job and lifestyle require that you work/play outdoors?

Do you wax your facial skin on a regular basis?

Yes

No

New Field:

Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?

Yes

No

If yes, was it within the last month?

Yes

No

If you have fillers, both botox or cosmetic surgery

Are you using Retin-A?

Yes

No

Are you using Benzoyl Peroxide?

Yes

No

Do you have any allergies or sensitivies?

Have you ever experienced a reaction to any of the following?

cosmetics

medicines

iodine(shellfish)

latex

pollen

food/fruit

animals

fragrance

alpha hydroxy acids

sunscreens

Free Text

Do you have any of the below health issues?

Cancer?

Yes

No

Chemotherapy?

Yes

No

Circulatory issues?

Yes

No

High blood pressure?

Yes

No

Arthritis?

Yes

No

Hysterectomy?

Yes

No

Hormonal imbalances?

Yes

No

Thyroid?

Yes

No

Diabetes?

Yes

No

Pregnant?

Yes

No

Lactating?

Yes

No

Planning to be pregnant?

Yes

No

Psoriasis?

Yes

No

Recent surgeries?

Yes

No

Cold Sores?

Yes

No

Eczema?

Yes

No

Do you take any medications?

Accutane?

Yes

No

Antibiotics?

Yes

No

Birth Control?

Yes

No

New Field:

I have read and completed this quistionnaire truthfully. 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 are voluntary and I release the company and/or skin care professional from liability.

New Field:

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

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Home
Microdermabrasion
NanoStamp 360
FOR MEN
Facials
Waxing
Book Now
Client Intake Form

Contact Information

Phone: (561) 758-8386

Email: katderomano@gmail.com

Address: 1405 Alternate A1a,

Jupiter, FL 33469

Business Hours

Mon - Fri: 9:00 AM - 4:00 PM

Sat - Sun: Closed

Certified and Licensed in Cosmetology and Esthetician Skin Care

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