Client Intake Form

Client Intake Form
Date

Month Day Year
Date
Name

First Name Last Name
Date of Birth
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Referred By
What are your top 3 skincare concerns at this time?
Have you ever used, or are currently using Retin-A, Renova, Resorcinol, or any other powerful AHA? Last time used?
Have you ever used acne medication? If so list below:
Any health concerns or conditions I should be aware of?
List any allergies (include aspirin & iodine)?
Type a question
Check any treatments you’ve had

Microdermabrasion Chemical Peels Laser Waxing Facial
Skin Conditions: Check all that apply

Skin infections Herpes (cold sores) Keloids/excessive scarring Sun sensitivity Skin cancer Poor healing Tattoos/permanent makeup Easy bruising Eczema Psoriasis
What type of skin do you have?
What is your skin care routine?

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