Facial Intake Form

Facial Intake Form

Luxe Skin Studio
Client Information
Client Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Occupation*
How did you hear about us?*
Medical / History Data
Are you pregnant, breastfeed, or nursing? (Female)*

YesNo
Do you have any allergies? If yes, what?
Are you currently taking any medications? If yes, please list them below:
Have you been under the care of a Dermatologist in the past year? If yes, for what?
Have you received Botox injections in the past six months?

YesNo
In the past 30 days have you received any Chemical Peels, Microdermabrasion or Laser treatments?

YesNo
Do you currently use Retin-A, Renova or Vitamin-A (Retinol)?

YesNo
What skincare products are you currently using? (list brand where known)*
What is your skin type?*

NormalDryOilyCombination
What concerns do you have for your skin? (select all that apply)*

Dark Spots/Age SpotsDrynessOilinessAcneTextureRednessUneven Skin ToneFine Lines/WrinklesOther
What would you like to achieve from your appointment? Is it more of a pampering time for yourself or do you have specific skincare concerns?
Do you have any additional information you would like to let your Esthetician know before your scheduled appointment?
Authorization
I have completed this form to the best of my ability and knowledge and agree to inform the esthetician of any changes in the above information. I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatments received. The treatments I receive here at Luxe Skin Studio are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
Client Signature*

Clear
If under 18, Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature

Clear
Should be Empty:

Facial Intake Form

Client Information

Medical / History Data

Authorization