Name
*
First Name
Last Name
Preferred Pronouns
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Preferred Phone
*
(###)
###
####
Preferred Method of Contact
Occupation/Job/Student
*
Does your job require you to work outdoors?
Yes
No
How did you learn about Mansfield Hollow Skincare?
What would you like to achieve from your treatment today?
*
Have you ever had a facial treatment before?
*
Yes
No
If yes, when?
Which best describes your skin type?
*
Creamy Complexion – Always burns easily, never tans
Light Complexion – Always burns, tans slightly
Light/Matte Complexion – Burns moderately, tans gradually
Matte Complexion – Seldom burns, always tans well
Brown Complexion – Rarely burns, deep tan
Black Complexion – Never burns, deeply pigmented
Do you have any special skin problems or concerns pertaining to your face or body?
*
Yes
No
If yes, please specify
Have you ever had chemical peels, laser or microdermabrasion?
*
Yes
No
In the last month?
Yes
No
N/A
Do you use Prescription topical products like Retin-A, Renova, Adapalene, Hydroxyl Acid products?
*
Yes
No
Have you had Botox, Restylane, Fillers or Collagen injections in the last 2 weeks?
*
Yes
No
What skincare products are you currently using?
Have you used any of these facial hair removal methods in the past six weeks?
What areas of concern do you have regarding your Skin?
*
What have you done about this concern so far?
Have you ever had an allergic reaction to any of the following?
*
Please explain
Do you have intolerance to Hot or Cold?
Are you Claustrophobic?
*
Yes
No
Please list any health conditions such as heart conditions, cancer, thyroid disease
Do you have a family history of skin cancer?
*
Yes
No
Have you ever had any of the following skin conditions?
Check all that apply
Current medications and/or vitamins
*
Dietary Considerations
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
*
Yes
No
If yes, please specify
Are you taking oral contraceptives?
Yes
No
If yes, please specify
Any recent changes to or from your contraceptive treatment?
Yes
No
If yes, what and when?
Are you pregnant or trying to become pregnant?
*
Yes
No
Are you lactating?
*
Yes
No
Any menopause problems?
Yes
No
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Ingrown Hairs?
Yes
No
Check to show you agree:
*
Check to show you agree:
*
Check to show you agree:
*
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*
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*
Check to show you agree:
*
Please acknowledge MHS Policies by typing name
*
First Name
Last Name
