Intake Form

Tell us about your skin before we meet.

This takes about five minutes. All video consultations take place via Zoom or FaceTime. In-person consultations take place in Davie, FL.

Full name

Date of birth

Phone

Preferred consultation type

Skin type

Sun exposure / SPF habits

Primary concerns (select all that apply)

Acne / breakouts Hyperpigmentation Fine lines / aging Redness / sensitivity Dullness / texture Dehydration

Current products you're using (optional)

Known allergies or sensitivities (optional)

Current or recent medications/treatments — including Accutane, prescription retinoids, or chemical peels (optional)

Any diagnosed skin conditions from a physician (optional)

What are you hoping your skin looks/feels like in 90 days?

Typed signature (full name)

Date

Your responses are sent securely to BK Skin Studio.