Health History Form

Your Skin

Is this your first professional skin treatment?

What are your top three skin goals?

hydration
improved texture
clear skin
even skin tone
refined pores
firmer skin
sculpted/lifted features
calm skin/ reduced redness
radiance/ glow

Check off all the specific skin concerns/ challenges that you would like to target with your treatment today.

Please share any further details that you would like your skin therapist to know prior to your visit.

What skin care products are you currently using?

Do you use: Retin-A, Renova, Adapalene or any other prescription skin products?*

Yes
No

If yes, was it in the last 3 months?

Yes
No

Are you currently using products that contain any of the following ingredients?

hydroxy acids (glycolic, lactic, salicylic etc.)
exfoliating scrubs
vitamin A derivatives (Retinol, Retin-A, Retinyl Palmitate)

Do you use sunscreen daily?

Yes
No

If yes, please specify what SPF you use for both face and body.

Makeup

Body products

bar soap
shower gel
scrubs
oil
body moisturizer
depilatory products
self-tanner

Your Routine

Feel free to share as much detail as possible with us, such as specific products you are using, so we can better analyze your current routine and skincare needs.

Do you use facial tools? eg: gua sha, facial rollers, microneedler, nuface, cleansing brush etc.

Yes
No

If yes, please specify which and how often:

Facial hair removal

If applicable, please indicate your preferred method of facial hair removal.

razor
electric shaver
plucking
waxing
depilatory cream
laser

Have you ever had:

chemical peel
microdermabrasion
laser
intense pulsed light
dermaplaning
microneedling
radio frequency skin tightening

If yes, please specify when you last received this treatment.

Choose which best describes your skin’s response to the sun.

always burns, blisters and peels
often burns, blisters and peels
burns moderately
burns rarely, if at all
never burns

Have you ever been diagnosed with melasma?

Yes
No

Do you have a tendency to flush/ experience skin redness?

Yes
No

Have you ever been diagnosed with rosacea?

Yes
No

Do you ever experience a burning, itching, or stinging sensation on your skin?

Yes
No

Client Waiver*

I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. By my signature below, I give consent for esthetic services rendered by Collective Skin Care and its affiliates.
I have been informed and advised of all risks associated with the services and procedures I will be receiving*.
I agree to comply with the instructions provided by the service provider.

*Information about potential risks is provided through Collective Skin Care's online booking system.

Consent*

I hereby release Collective Skin Care, its affiliates and directors from liability for any injury, loss or damage that may result from any services provided or treatments rendered. This release binds my heirs, successors and assigns.

Cancellation policy and credit authorization release*

We request 24 hours notice for cancellations or appointment changes. Cancellations within 24 hours of the scheduled service are subject to a charge equal to 100% of the booked appointment.

I understand the cancellation policy and agree to pay any cancellation fees I incur.

Parent / Legal Guardian (required for minors)

First Last

Consent for Minors

I give permission for my ward to be treated by Collective Skin Care

Comments

This field is for validation purposes and should be left unchanged.

Step 1 of 3

Skin Health Intake Form

Your Health

Hormonal Health

Your Skin

PARKING