Esthetics Intake Form

Esthetics Intake Form

Please provide your personal information below. Thank you!
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
Full Name*
Please type first and last name.
D.O.B. (MM/DD/YYYY)*
Phone (DAYTIME)*
Phone (EVENING)
Email Address*
example@example.com
Occupation
How did you hear about us?
Conditions you are currently experiencing today (Please select all that apply):

HeadacheInflammationMuscle CrampsAnxietyFatigueInsomniaStressForgetfulness
Which aroma(s) do you prefer? (Please select all that apply)

LavenderCitrusGeraniumPeppermintLemongrassPatchouliEucalyptusFrankincense
Esthetics Information
What type of skin do you have?

NormalOilyDryCombination
Have you been under the care of a dermatologist within the past year?*

YESNO
If yes, please explain...
What areas of concern do you have regarding your skin?

Breakouts/AcneBlackheads/WhiteheadsUneven Skin ToneSun DamageExcessive Oil/ShineWrinkles/Fine LinesDull/Dry SkinRosaceaBroken CapillariesRedness/RuddinessDehydratedSun, Liver, Brown SpotsOther
Have you ever had an allergic reaction to any of the following?

CosmeticsMedicineFoodAnimalsSunscreenDrugsIodinePollenAHAsFragranceShellfishLatex
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products?*

YESNO
If yes, please describe...
Have you received Botox, Restylane, or Collagen injections in the last 6 months?*

YESNO
If yes, please specify...
Client Signature*
Should be Empty: