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Clean Beauty Quyen
About
Appointment
Services
Portfolio
Contact
Client Intake Form
Client Intake Form
*this form is required for NEW CLIENTS only.
Name
*
First Name
Last Name
How did you find CBQ?
*
Referral
Social Media
Yelp
Google
Other
Do you have any of the following health conditions?
*
Check all that apply:
AIDS/HIV
Cancer
Diabetes
Heart Problems
Hepatatis
High/Low Blood Pressure
Lupus
Recent Surgery
Stroke
Depression
Eating Disorder
Anxiety
None
Stress Level
*
Low
Moderate
High
Do you smoke?
*
Yes
No
Do you drink?
*
Yes
No
Skin Concerns
*
Which concerns apply to your skin? Check all that apply:
Uneven Skin Tone
Fine Lines / Slow Aging
Acne
Scarring
Texture
Dark Spots
Dryness Clogged Pores
Broken Capillaries
Redness/Ruddiness
Dull/Dry
Dehydrated
Sun Damage
Skin Disorder
*
Acne
Eczema
Rosacea
Psoriasis
Perioral Dermatitis
Unknown
None
Currently On Medication
*
Check all that apply:
Accutane
Retin-A
Birth Control
Topical Vitamin C
Hydroquinone
Other
None
Are you currently pregnant?
*
Yes
No
Have you been under the care of a dermatologist within the past year?
*
Yes
No
Have you received Botox, Restylane, Collagen or facial surgery in the last 6 to 12 months?
*
Yes
No
Current Age Range
Pre-teen
Teen
20 to 30
40 to 50
60 +
Last Facial?
*
1 month ago
6 months ago
12 months ago
12 months +
Never had a facial
Current skincare routine? Include products.
List your allergies (ie food, seasonal +etc).
What are your long term skin goals?
By selecting the check box I agree that I answered truthfully and/or to the best of my knowledge.
*
Yes I understand
Thank you!