ADS Evaluation Form

Allana Davis Studio — Client Intake & Consent

Thank you for completing this form. It takes about 3 minutes. Share only what feels relevant — this helps me tailor your treatment safely and effectively.
Todays Date*

MonthDayYear
Date
Personal Information
Date of Birth

MonthDayYear
Date
Full Name*

First NameLast Name
Cell Phone

Area CodePhone Number
E-mail*
Who can we thank for referring you?
Name (or ‘Instagram / Google / Walk-in’)
What are you looking to improve?*

Breakouts / acneDark spots / pigmentation / melasmaFine lines / aging supportRedness / sensitivityDryness / dehydrationTexture / roughnessCongestion / blackheadsDullness / glowI’m not sure yet — I want your guidance
If you could change ONE thing first, what would it be?*
Anything you’d like me to know before your appointment? (optional)

Skin Care & Active Product Use

This helps me adjust your treatment safely. If something doesn’t apply, simply select ‘No.'
Are you currently using any active skin care products? Examples: retinol, Retin-A, glycolic acid, salicylic acid, benzoyl peroxide.*

YesNo
Please list the product(s) and how often you use them.*
Have you ever reacted to a Vitamin C product? Reaction may include stinging, redness, inflammation, or breakouts.*

YesNo
Briefly describe the reaction (optional)
Reaction may include stinging, redness, inflammation, or breakouts.”
Have you had any adverse skin reactions in the past 12 months?

Consent & Acknowledgements

Please review and acknowledge the following so we can proceed with your treatment safely.
Treatment Consent*

I understand that skin care treatments may involve risks such as redness, sensitivity, irritation, or changes in pigmentation. I confirm that I have disclosed all relevant medical information and understand that I am responsible for informing my practitioner of any changes to my health history prior to future appointments. I understand results vary from person to person.
Post-Treatment Care*

I understand that following post-treatment instructions is essential for optimal results and healing.
May we take before/after photos for your client file?*

YesNo
Appointment & Cancellation Policy

I understand that appointments canceled with less than 24 hours notice, late arrivals, or no-shows may incur the full service fee.
Cancellation Policy Acknowledgement*

I have read and agree to the cancellation policy.
Milia Removal Consent*

I understand that milia removal may cause temporary redness, sensitivity, or minor pinpoint bleeding and consent to treatment.
Final Acknowledgement*

I confirm the information provided is accurate and complete to the best of my knowledge.
Date (Signature Date)*

MonthDayYear
Signature*

Clear
Should be Empty:

Allana Davis Studio — Client Intake & Consent