Client Intake Form *ALL CLIENTS MUST FILL OUT ONCE

Name

Date of Birth

Date

Address

Phone #

Format: (000) 000-0000.

Email

example@example.com

Preferred contact method

Please LIST the following:

Allergies to Foods/Medications/Products & Type of Reaction

Medications

Medical Conditions

Please SELECT if you have any of the following:

Do you smoke?

Do you wear contact lenses?

Do you have any metal implants, pacemaker, metal piercings, or defibrillator?

If yes, please specify

Do you sunbathe or use a tanning bed?

Within the last year, have you been under a dermatologist's care?

Do you use Retin-A, adapalene, or other prescription skin products?

Have you taken isotretinoin (Accutane) in the past 6 months?

Are you currently using any products that contain glycolic acid, lactic acid, exfoliating scrubs, hydroxy acid, or retinol?

Do you experience flakiness, tightness, or dryness with your skin?

Do you use SPF sunscreen daily? Yes / No If so, what SPF?

Do you use SPF sunscreen daily?

If so, what SPF?

Do you burn easily in moderate sunlight?

Do you have a tendency for redness?

Do you have any permanent makeup or tattoos?

Are you taking any blood thinners or aspirin?

Have you ever experienced claustrophobia? Yes / NoAre you pregnant or breastfeeding? Yes / No Are you trying to become pregnant? Yes / NoDo you have any shaving challenges? Yes / No

Have you ever experienced claustrophobia?

Are you pregnant or breastfeeding?

Are you trying to become pregnant?

Do you have any shaving challenges?

Please Specify

What concerns you the most about the overall appearance of your skin? (Circle all that apply) Acne Scarring Bumps on Arms Dull Complexion Dehydrated Skin Cysts/Nodules Large Pores Frequent BreakoutsRough/Uneven SkinSun Damage Oily Skin

What concerns you the most about the overall appearance of your skin?

How would you describe your skin (Check Answers)?

Is there anything else you would like me to know about your health or your skin?

Rate your stress level on a scale of 1 to 5 (1 = low; 5 = high)

What are your expectations with your treatment(s)?

How did you hear about Katherine Booth Skincare and Spa?

Social Media/Photo Consent: For marketing and educational services, I often post photos and/or videos to my social media accounts including Facebook and Instagram. These may include before and after photos. Do I have permission to take and post photos/videos of you for my business use?

Client Signature

Date

KB SKINCARE & SPA