Client Intake Form | Enveil Institute

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Clinical Client Intake Form

Powered by Seren Clinical Care

Please complete this form thoroughly and honestly so we can better understand your skin concerns, current routine, and corrective goals before your assessment begins.

First name*

Last name*

Email*

Skin Concerns *

Type of Inquiry*

Acne

Hyperpigmentation

sensitivity

Texture

Dryness

Oiliness

Barrier Damage

Aging Concerns

Redness

Other

Current Routine

Current Serums/Treatments

Moisturizer

SPF

Prescription Products

Stress Level

1-10

10-20

Water Intake

2-3 glasses

8 glasses

Sleep Quality

5-6 hours

8-10 hours

Hormonal Changes

Diet Triggers

Smoking/ Vaping

Recent Treatments

Skin History

Check What applies

Accutane history

Allergies

Pregnancy/breastfeeding

Eczema

Rosacea

Peels/lasers

Prescription retinoids

What are your Main Skin Goals

Upload a Photo Front Facing natural light left side, right side No filters No make up .

What have you tried previously that did not work for you?”

Enveil institute and Seren Clinical Skincare do not diagnose medical conditions. Recommendations are educational and cosmetic in nature and are not substitute for medical care.

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enveilskincare@enveilskinboss.com

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