Intake Form - Joy+Honey Skincare

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Intake Form
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Joy+Honey

Services & Booking
Shop
Intake Form
Contact/Location
Joy+Honey

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!

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

When was your last facial?

What type of facial did you get?

Does your job require that you work outdoors?YesNo

Which of the following best describes your skin type?

Do you have any special skin problems or concerns pertaining to your face or body?YesNo

Please Specify

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

Any concerns regarding your eyes:

DehydratedWrinklesPuffinessDark Circles

Any concerns regarding your lips:

Dry/DehydratedCracked/Chapped

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

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?

Female Clients

Are you taking oral contraceptives?YesNo

Any recent changes to or from your contraceptive treatments?YesNo

If yes, please specify when

Are you pregnant or trying to become pregnant?YesNo

Are you experiencing any menopausal symptoms?YesNo

Are you undergoing any hormone replacement therapy treatments?YesNo

Male Clients

Do you experience irritation from shaving?YesNo

Do you experience ingrown hairs as a result of hair removal?YesNo

May I mail/email you about future promotions and news?YesNo

May I text you about future promotions and news?YesNo

Todays Date *

Month *

Day *

Year *

Text Message Agreement

By signing and submitting this form, I agree to receive appointment related text messages, such as confirmation, follow-up and reminders.

Signature *

Start signing your signature here

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3607 West Magnolia Blvd
Suite 9, Second Floor
Burbank, CA 91505
818-850-3704

Services & Booking
Shop
Intake Form
Contact/Location
Joy+Honey