First Name
Last Name
Date of Birth (mm/dd/yyyy)
/ /
Gender
Email Address
Day Phone #
Other Phone #
How would you prefer to be contacted?
Phone
Email
How did you find us?
If so, whom?
Client Referral
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Search Engine
Heather Kleinman
Please list any others
Please check if you are on any of the following:
Retin A
Date Started
Problems?
Retin A Micro
Metra Gel
Vitamins
Brand Name
Hormones
Birth Control
Antibiotics
Herbal/ Homeopathic remedies
Benzoyl PeroxideTreatments
Is it a BP Facial Wash, Cream, or Other (please describe)
Cosmetic Botox
Date Started and Number of Treatments
Results
Photore- juvenation Treatments
Diet Pills
Other
Eye Color
Natural Hair Color
Do You Smoke?
If so, for how long?
Do you use:
Sunbathe?
Mystic Tan?
Fake and Bake?
If so, how often?
How often do you wear sunscreen?
What strength SPF do you normally wear?
Daily While Tanning Only On Vacation
Is your SPF in your make-up?
Yes No
How many hours to you spend outdoors weekly?
How many times a day do you wash your face?
Once Twice More Other
Reason why you wash more than once or twice daily
Do you currently have any skin conditions?
If so, what and for how long?
Describe the texture/condition of your skin
Do you notice a change in your skin with changes in seasons or the weather? Yes No
If so, what are the changes and when do they occur?
Please check boxes if any of the following cause flare ups
Stress Exercise Menstrual Food
If so, what foods?
Please List
Does your skin react to any of the following?
Heat Cold Wind
If so, how?
How does your skin feel in the A.M. hours with make-up?
Without make-up?
What type of make-up do you use?
Are you allergic to any comsmetic or product ingredients?
Powder Liquid Mineral
If so, please list (be specific)
Does your skin ever react to any cosmetic or product ingredient? Yes No
Are you currently under the care of a dermatologist or esthetician Yes No
Do they currently have you on a treatment program? Yes No
If so, please describe
Does you currently have a skin care regime? Yes No
Is there anything else you would like me to know about your skin in order to custom blend your products?
At Clinical Basic Skin Care® we value your privacy. We will not use your personal data for any purpuse that you have not agreed to and will never sell your personal data to third party list, brokers, or direct marketing companies.
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