Client Intake Form

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:
ex. 555-555-5555
Birthdate:
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
How did you hear about Holistic Skin Expert?

Preparing for your appointment
Please bring all of the products you currently use to your appointment, or fill them in below. Each of the current products will be assessed. After your treatment you will be given a detailed product regimen to follow at home. This may include some of your original products that are approved for use. Additional and/or replacement products will be added. Your personalized regimen is designed to strengthen, repair, correct, condition and maintain your skin throughout your treatments. This allows the skin to be healthy enough to accept the more advanced modalities that will be used on the skin.
Current skin care products you use at home. Include brand names and product names.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Holistic Skin Expert and/or the skin care professional from liability and assume full responsibility thereof.*

I understand
To cancel an appointment please contact at 708-769-5351 or paulina@holisticskinexpert.com at least 48 hours prior to your appointment. Cancellations less than 48 hours or "No Show" will be charged full amount of the scheduled service.*

I understand the cancellation policy.
OPTIONAL: I grant permission to Holistic Skin Expert to use photos of my progress for marketing purposes on www.holisticskinexpert.com or other business listing pages such as Instagram

I grant permission.
Date*

MonthDayYear
Signature*
Should be Empty:

Medical & Skin History