Skincare Intake Formulier EN

Name:
Date of Birth:
Streetname & Housenumber:
Postal code:
Residence:

Phonenumber:
E-mail:
Profession:

How did you end up at Skins Laser Clinic?
google, advertisement, mouth-to-mouth

What are we going to improve on your skin? How and when did this arise?

Does your face ever feel dry, tight or greasy? Describe here.

Do you have sensitive skin? Ever had an allergic reaction? (Think also of vegetables or fruit)

Do you ever go to a skin specialist or skin therapist? If so, where do you go and what kind of treatment do you receive?

Have you had an aesthetic treatment before? Botox or fillers?

Do you suffer from claustrophobia, fear of small enclosed spaces?
Yes / No YesNo

How satisfied are you with your health right now?

Are you pregnant or trying to conceive?

Have you ever suffered herpes?
YesNo

Do you use medication? Yes? What is the medication for?

Have you ever used roaccutane (acne medication)?

Do you smoke?
YesNo

How many liters of water do you drink on average per day?

Do you eat enough dairy, vegetables, fruit, oily fish, nuts?

What is your average stress level 0 – 10?
012345678910

Are you going under the tanning bed?
YesNo

What products are you currently using for your skin? (you may also mention product names etc.)

How often do you clean your skin per day?

Date:

Full name:

Signature:
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