Intake Form

Welcome to Joy+Honey. Please complete the following intake form before your first visit to better customize your treatment. We look forward to meeting you!

Woman receiving a relaxing facial treatment at Joy+Honey skincare studio in Burbank

First Name *

Last Name *

Email Address *

Phone *

Birth Day and MonthEnter the month and birth day.

I am *

How were you referred to Joy+Honey? *

Other referral method

Name of Referral *

What would you like to achieve from your treatment?

Have you ever had a facial before?YesNo

Which of the following best describes your skin type?

Have you ever had chemicals peels, laser treatments, or microdermabrasion?YesNo

Was your treatment within the last month?YesNo

Do you use or have ever used Acne Medication, Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?YesNo

Please specify what and when last used:

Have you had Botox, Restylane, or collagen injections?YesNo

Please specify when and what type:

What skin care products are you currently using?CleanserTonerDay MoisturizerNight MoisturizerExfoliatorMaskEye ProductSPF/SunscreenScrubsMakeup ProductsSoapOther

Other Product

Have you used any hair removal methods in the past six weeks?YesNo

Select the hair removal method:ShavingWaxingPluckingTweezingThreadingDepilatories

Select the areas of concern that you have regarding your skin:Breakouts/AcneSun DamageRosaceaFlaky SkinSun/Liver/Brown SpotsUneven Skin ToneExcessive Oil/ShineDull/Dry SkinRednessBlackheads/WhiteheadsWrinkles/Fine LinesBroken CapillariesDehydrated

Have you ever had an allergic reaction to any of the following *FruitShellfishFragrancePollenLatexType of FoodNutSunscreensAlpha Hydroxy Acids (AHA's)Milk/DairyOtherNone

List Nut

List Food

List Fruit

List Shellfish

List Fragrance

List AHA's

List Other Allergies

Do you use SPF on your face?YesNo

How many glasses of water do you drink per day?

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?

How many alcoholic beverages do you consume per week?

Do you smoke cigarettes, vape, or consume other tobacco products?YesNo