The Beauty Room

Skin Consultation Intake Form

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1. Consultation

Consultation type
How did you hear about me?*

2. Your Skin

Skin type*
Is your skin sensitive or easily irritated?*
How does your skin react to the sun?*
Top skin concerns (check all)*
What would you most like to fix first?
What results are you hoping for?

3. Current Skincare

Morning routine: list each product and brand
Evening routine: list each product and brand
Are you currently using any of these? (check all)*
Do you wear sunscreen daily?*
Products that have irritated or broken you out before

4. Health & History

Prescription skin medications
Have you taken Accutane/isotretinoin in the past 12 months?*
Allergies
Are you pregnant, trying to conceive, or breastfeeding?*
Check any that apply*
Recent treatments in the past 3 months (check all)*

5. Lifestyle

Daily water intake*
Average sleep*
Stress level*
Do you smoke or vape?*
Anything else about your skin, health, or lifestyle I should know?

6. Acknowledgment