Client Intake/ Consultation Form

Name
Date of Birth

MonthDayYear
Date
Address
Telephone
Format: (000) 000-0000.
E Mail
example@example.com
YesNo
Emergency Contact
Telephone
Format: (000) 000-0000.
Your Skin Goals and Concerns
SensitiveMild AcneOilyDryModerate AcneMature & AgingNormal/Combo
What skin products are you currently using?
YesNO
YesNo
What makeup products are you currently using?
YesNo
If yes, when was the last time, and what treatment?
cosmeticsmedicinelatexpollenIodine (shellfish)animalsfood/fruitbenzoyl peroxide?fragrancealpha hydroxy acidssunscreens
Do you have any allergies or sensitivities?
YesYes
NoYes
NoYes
NoYes
Do you take any medications?
Are you under a Physician/ Dermatologist care?
I have read and completed this questionnaire truthfully. , understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and / release the company and/or skin care professional from liability.
Signature

Clear
Date

MonthDayYear
Date
Normal/ComboOilySensitiveMild AcneModerate AcneDryMature & Aging
Should be Empty: