Esthetics Intake Form

Esthetics Intake Form

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

Month Day Year
Date Hour Minutes AM/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):

Headache Inflammation Muscle Cramps Anxiety Fatigue Insomnia Stress Forgetfulness
Which aroma(s) do you prefer? (Please select all that apply)

Lavender Citrus Geranium Peppermint Lemongrass Patchouli Eucalyptus Frankincense
Esthetics Information
What type of skin do you have?

Normal Oily Dry Combination
Have you been under the care of a dermatologist within the past year? *

YES NO
If yes, please explain...
What areas of concern do you have regarding your skin?

Breakouts/Acne Blackheads/Whiteheads Uneven Skin Tone Sun Damage Excessive Oil/Shine Wrinkles/Fine Lines Dull/Dry Skin Rosacea Broken Capillaries Redness/Ruddiness Dehydrated Sun, Liver, Brown Spots
Have you ever had an allergic reaction to any of the following?

Cosmetics Medicine Food Animals Sunscreen Drugs Iodine Pollen AHAs Fragrance Shellfish Latex
Do you currently or have you used in the last 3 months Retin-A, Renova, AHA's, or Retinol/Vitamin A derivative products? *

YES NO
If yes, please describe...
Have you received Botox, Restylane, or Collagen injections in the last 6 months? *

YES NO
If yes, please specify...
Client Signature *

Clear
Should be Empty:

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Esthetics Intake Form

Esthetics Information