Language
English (US)
Spanish (Latin America)
Client Intake Form:
Please, fill out this one-time form at least 24 hours prior to your appointment. Be advised that your appointment may be rescheduled if any contraindications apply. Thank you for your preference, La Muse Skin.
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Birthday
Were you referred by a client of La Muse Skin? If so, what's their name
First and Last Name
How would you describe your skin type? Check all that apply
Dry
Combo
Oily
Normal
Sensitive
What are your skin concerns? Check all that apply
I experience a lot of breakouts
My Breakouts are painful
My nose looks like it has a lot of blackheads
I want to remove peach fuzz
I have discoloration
I have scarring leftover from acne
Products irritate my skin
My skin looks dull
My skin is often greasy
My skin turns red easily
I see fine lines on my skin
I want to lift/tighten my skin
What is your relationship with skincare?
I love trying new products
I have a routine that works for my concerns
I don't feel like my products are targeting my concerns
I don't know much about skincare
Have you been under the care of a dermatologist within the past year? If so, what for?
Do you currently use Accutane, Retin-A, or any other prescription skin care products? If so, what products?
Have you received any injectables such as Botox etc.? If so, what treatment and how long ago?
Have you been diagnosed with skin diseases/disorders by a doctor? Please, specify.
Have you received chemical peels, microdermabrasion, derma plane, or any other resurfacing treatments? If so, what and how long ago?
Do you have allergies or sensitivities? If so, please specify.
Are you pregnant, lactating, or trying to become pregnant? Please, specify.
List medications you take regularly
List any skin treatments you receive regularly (waxing, etc.)
List any dietary restrictions
Do you smoke, consume alcohol/caffeine regularly? Please, specify.
Do you wear makeup regularly?
Do you wear sunscreen? (not included in makeup) If so, how often?
Do you tan indoor or outdoors?
List all skincare products and brands you are currently using. (cleansers, exfoliants, toners, serums, moisturizers, oils, masks, SPF, tools, etc.) Please, be specific.
How often do you use your skincare? Check all that apply.
Morning
Middle of day
Night
Neither
Are you claustrophobic?
Yes
No
My Favorite part of a Facial is:
Are there any treatments you'd like more info on? Check all that apply.
Dermaplane
Nano Infusion
Lift and Contour treament
Lash Lift
Brow Lamination
Waxing
Back facial
How did you hear about La Muse Skin, LLC.
Referral
Instagram
Found business card
Other
I give Nancy Brito of La Muse Skin LLC. permission to take photos and/or videos of me during my service for promotional/educational service. Also, to keep track of my progress.
*
I agree
If I experience any pain/discomfort during my treatment I will immediately make Nancy aware so that my treatment may be adjusted to my comfort. I further understand that aesthetic treatments should not be considered substitutes for medical examination, diagnosis, or treatments. Nothing in the course of my treatment should be constructed as a diagnosis, treatment, or prescription. Certain aesthetic treatments should not be performed under certain medical conditions or medications, therefore I affirm that I have stated all my medical conditions and medications. I agree to update Nancy Brito of La Muse Skin, LLC. of any change to my medical profile, and I understand that there shall be no liability on La Muse Skin, LLC. or Nancy Brito if I should fail to do so.
*
I agree
Signature
Date
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Month
-
Day
Year
Date
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