Client Intake Form

Client Intake Form

Client should complete the following, as directed, as thoroughly and in as much detail as possible.
Name*

First NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Phone Number

Area CodePhone Number
Birthdate:*
Occupation:*
Emergency Contact, and relation to contact:*
Phone Number*

Area CodePhone Number
How did you hear about Chase Beauty?*
Please indicate which of the following you are interested in. (Check All That Apply):

Skin Care Advice/ConsultationHome Care ProductsClinical TreatmentsAge ManagementAcne ManagementRosacea Management
What are your goals for your skin?*
Medical History
Are you currently, or have you previously experienced any of the following (Check All That Apply):

Heart ConditionContact LensesPacemakerHeadachesAnemiaLow Blood PressureHigh Blood PressureCancerThyroid ConditionKidney ProblemsHemophiliaAsthmaDiabetesHypo/Hyper glycemiaHepatitisHerpes SimplexAIDS/HIV PositiveAutoimmune DisorderEpilepsy/Seizure DisordersKeloid scarring
If you are currently experiencing or being treated for any health or skin-related condition/disorder, please describe:
Please indicate if you have ever used any of the following medications for skin treatment (check all that apply):

Accutane (Isotretinoin)CortisoneBenzoyl PeroxideRx Retin-AAdapaleneMetrogelDifferinEpiduoTazoracFinaceaAczoneClindamycinAzelaic AcidSalicylic AcidGlycolic AcidLactic AcidN/A
What condition were you treating with this medication, and when was the last time it was used?*
Have you had a surgical or non-surgical procedure within the past 5 years? if yes, where on the body was the surgery performed?*
Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side effect:*
Please list all over-the-counter medication, supplements, and/or prescription medications you are currently taking:*
Women

Female and female-identifying clients please fill out the following:
Are you currently pregnant?

YesNo
Are you currently breastfeeding?

YesNo
Are you going through menopause?

YesNo
Are you currently on any type of hormone therapy or birth control?

YesNo
If yes, please describe:
Skin Self-Analysis:
Is your skin (check all that apply):

OilyAcne proneDrySensitiveNormal
What is your ancestry, if known (ex: Latinx, Irish, Indian, Asian, etc):*
What skincare products are you currently using? Please list what type of product (cleanser/toner, etc), the brand, and how you use them AM/PM:*
Are you currently wearing daily sunscreen?

YesNo
Lifestyle & Stress Analysis
Do you use tanning beds?*
Do you smoke or vape tobacco?*
What is your stress level?*
How much water do you drink daily?*
What is your average hours of sleep a night?*
Please indicate any of the following that apply to your eating habits:

Fast FoodBaked BreadSeafoodDairy productsPeanut butter/peanut productsPre-workout supplements
Client Consent
I consent to "before and after" photos for the purpose of documentation, potential advertising, and promotional purpose.

Yes to allDocumentation Only
I have answered the above questions truthfully and to the fullest extend of my knowledge, and I understand and agree that I am ultimately responsible for payment in full for services received.

YesNo
Should be Empty:

Client Intake Form

Medical History

Women

Skin Self-Analysis:

Lifestyle & Stress Analysis

Client Consent