Client Intake Consultation Form

Name
Date of Birth

MonthDayYear
Date
Address
Telephone
Format: (000) 000-0000.
E Mail
example@example.com
NoYes
Emergency Contact
Telephone
Format: (000) 000-0000.
Your Skin Goals and Concerns
Normal/ComboOilySensitiveDryMild AcneModerate AcneMature & Aging
Do you wax your facial skin on a regular basis?What makeup products are you currently using?
What skin products are you currently using?
Does your job and lifestyle require that you work/play outdoors?
Does your job and lifestyle require that you work/play outdoors?Yes No
If yes, when was the last time?
cosmeticslatexiodine (shellfish)pollenfood/fruitmedicineYes NosunscreensYesNo
No YesIf yes, was it within the last month?
Yes NoAre you using Benzoyl Peroxide?Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?If yes, when was the last time?
Do you have any allergies or sensitivities?
Have you ever experienced a reaction to any of the following?

Do you have any of the below health issues?:
Yes NoDo you have any of the below health issues?:YesNoChemotherapy?YesNoYesNoHigh blood pressure?YesNoYes NofragranceHysterectomy?YesNoHormonal imbalances?YesNoThyroid?YesNoYesNoPregnant?Diabetes?YesNoYesNoPlanning to be pregnant?Lactating?YesNoPsoriasis?Yes Noalpha hydroxy acidsYesNoCold Sores?YesNoanimals
Yes Accutane?NoDo you take any medications?Antibiotics?YesNoBirth Control? YesNoEczema?Recent surgeries?
Do you take any medications?
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.
Signature
Date

MonthDayYear
Date
IVVVI
SensitiveMild AcneModerate AcneDryMature & AgingOily
2.
3.
Cleanser
Cleanser
Exfoliant
Exfoliant
Toner
Toner
Serum
Serum
Moisturizer
Moisturizer
SPF
SPF
Should be Empty: