Holistic Skinmagic's Client Intake Form
By signing this form you are consenting to get the service you booked and paid for. you have agreed to Holistic Skinmagic's terms and conditions. by signing you are stating that you are being 100% truthful in all your answers and are not withholding any important health related information. all information collected is strictly confidential. *in the event that you withheld and hid any important health related information and experience any allergic reaction or health issue you are making yourself 100% responsible, Holistic Skinmagic & the esthetician performing the service will not be responsible for any dishonesty displayed by client*
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Your Birth Date
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Month
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Day
Year
Date
We would love for you to sign up for our promotional emails, these emails include holiday discounts, sales, giveaways and special gift/discounts on clients birthday.
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Yes, sign me up
No
Referred by:
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What would you like to achieve from your treatment today?
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Have you ever had a facial before?
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Yes
No
Which of the following best describes your skin type?
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Creamy Complexion - Always burns easily, never tans
Light Complexion - Always burns, tans slightly
Light/Medium Complexion - Burns moderately, tans gradually
Medium Complexion - Seldom burns, always tans well
Brown Complexion - Rarely burns, deep tan
Black Complexion - Never burns, deeply pigmented
Which of the following are your main concerns?
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Blackheads/Whiteheads
Acne/Oily skin
Dry/Dehydrated skin
Textured skin
Aging skin
Hyperpigmentation
Do you have any skin problems/concerns pertaining your face or body? please specify
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Have you ever had chemical peels, laser, or microdermabrasion? if yes when?
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Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Accutane, or any other Retinol/Vitamin A derivative?
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Are you currently taking any acne medication? if yes which drug?
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What are you allergic to? ex: cosmetics, medicine, latex, fragrance, food, pollen, AHAs
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Are you currently pregnant?
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Yes
No
Are you on birth control?
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Yes
No
Are you currently under the care of a physician or dermatologist?
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List all health problems you have or have had. ex: cancer, diabetes, heart problems, lupus, seizures, herpes simplex, HIV/AIDS, asthma, eczema etc.
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Appointment Date
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Month
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Day
Year
Date
Signature
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Submit
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