New Client Intake Form

New Client Intake Form
Client's Name

First NameLast Name
Gender

FemaleMaleNon-binaryI prefer not to say
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact’s Phone Number

Area CodePhone Number
Do you have any of the following conditions? If yes, please select them:

Metal Implants or Dental ImplantsPacemaker or DefibrillatorClaustrophobiaHormonal ImbalanceEpilepsy or SeizuresHIV or AIDSHepatitis A/B/CPsoriasisEczemaBruise EasilyImmune DisorderKeloid ScarringCirculation DisorderMRSAA Current Outbreak of Herpes Simplex Virus (please call to reschedule if scheduled for a facial)A Diagnosis of CancerDiabetesLupusHigh Blood PressureLow Blood PressureAcneRosacea/Blushes EasilyCurrent Rash that is Unknown or Specified (if on face please call to reschedule if scheduled for a facial)Sensitive eyesPCOSNoneCurrent Eye Stye (please call to reschedule if scheduled for a facial)Other
Do you have any of the following allergies? Please be very thorough and if your allergy is not listed below please specify in other. If you have no known allergies please choose none.

ShellfishIodineSulphurGlutenSoyTree NutsPeanutsMilkWheatEggsSeasonalBeesNoneOther
What do you think your skin type is?

NormalOilyDryCombination
Do you have an at home skin care regimen?

YesNo
Briefly describe how you take care of your skin at home.
Have you ever had a facial before?

YesNo
Do you have any skin concerns?

Crows feetFine lines on forehead or around mouthDeep wrinkles on forehead or around mouthDark circles around eyesLoss of firmness in faceMiliaDry or dehydrated skinSun or age spotsDull skinEnlarged or clogged poresExcess oilRednessAcne scarringSensitive skinMelasma or hyperpigmentationAcneNoneOther
Have you ever been waxed before?

YesNo
Have you ever had your eyebrows henna tinted or dyed before?

YesNo
Have you ever had an adverse reaction to a product, skin care treatment, waxing, or hair dye?

YesNo
If yes, please briefly explain what service or product caused the adverse reaction and how your skin responded.
Are you pregnant?

YesNo
Are you breast feeding?

YesNo
Are you using Accutane or have you used it in the last year? If yes, please call to reschedule.

YesNo
Are you using any products that contain Adapalene, Retinol, Retin-A, Tretinoin, Differin, Hydroquinone, Salicylic Acid, Glycolic Acid, Lactic Acid, Benzoyl Peroxide, any oral OR topical anti-biotics (Tazarac, spironolactone, doxycycline, minocycline, etc)

YesNo
If yes, please enter the product or medication you are currently using and the frequency. Please stop the use of that product 5-7 days prior to your facial waxing appointment or 3 days prior to your facial appointment to avoid any adverse reactions.
Have you had a chemical peel or microdermabrasion in the last 14 days?

YesNo
How did you hear about The Petite Aesthetician?

InstagramFacebookPostcardYelpGoogleNext Door AppWRNJReferral from a friendOther
If referred by a friend, please put their name below so they get credit!
Terms & Conditions
I understand that my data will be strictly confidential. The Petite Aesthetician does not sell, share, or resell information.

I confirm that all information in this form is true and accurate and if anything changes regarding the medications I am taking or the products I am using I will let my aesthetician know prior to receiving any service.

I confirm that if I withold any information or any changes to my skincare routine regarding new products or medications and complications occur, The Petite Aesthetician will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

I understand that after a skin consultation my aesthetician may suggest to use a surface peeling chemical exfoliate during my facial and I give consent. I know I can decline a chemical exfoliate prior to the service, but this must be expressed during the skin consultation.

I agree to any pre or post care The Petite Aesthetician suggests for services and if I do not follow these guidelines and there is an adverse reaction The Petite Aesthetician will not be held liable.

Cancelation & No Show Policy:
Please give 24 hour notice of your cancelation either through your email or text confirmation or by calling the shop at 908-441-6121. Cancelations or notification of being late will not be accepted through Instagram or Facebook direct messages.

Failure to do so or no showing will result in a fee of 50% of your service. This fee will be sent as an invoice and no services will be rendered until the fee is paid. Perpetual less than 24 hour cancelations or no showing will result in a required deposit for future services.

Late Policy:
There is a 5 minute late policy for 15 minute appointments and a 10 minute late policy for any services scheduled for 30 minutes or more. Please notify the shop if you are running behind by calling 908-441-6121 so we can plan accordingly. Failure to do so will result in you being recorded as a no show. Direct messages through Instagram or Facebook will not be accepted as notification of your late arrival.
Client Signature

Clear
*To sign this form while using a smartphone place your finger or stylus in the designated area and drag. If you are on a PC or laptop please click within the designated area and drag.
Photo Release (optional)
I authorize The Petite Aesthetician to use my photos on their website, Instagram, and Facebook for the sole purpose of showing before and after results from services and products rendered at the shop location. I understand that my name will not be disclosed in any photo or caption.
Client Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

New Client Intake Form

Terms & Conditions

Photo Release (optional)