Esthetics Client Intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Date of Birth
How did you hear about us?
What Type of Service are you getting done?
Have you ever had this type of service before?
What are the things concerning you about your skin, brows or lashes currently?
If you are getting a facial, what are the following skin care products you are using?
Are you pregnant?
Are you taking any medications?
If yes, please list name and use:
Do you have any allergies or sensitivities?
If yes, please list:
What concerns you most about the overall appearance of your skin or brows? (Check all that apply)
Rough/Uneven Skin Texture
Lightness of Brow hair
Uneven or Straight Lashes
How would you like the conversation level during your Treatment?
Do we have permission to show your non-identifying photos for educational purposes?
How would you describe your stress level?
By signing below you agree to the following:
We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your service provider and also means our other clients miss the chance to receive services they need.
Should be Empty: