Facial Client Intake & Consent Form

Facial Consultation & Intake Form

Help me customize your treatment by sharing a bit about your skin, health, and goals. As a licensed esthetician, your comfort, safety, and personalized care are always my top priority. All information provided is required for recordkeeping and security purposes. Your details are kept secure, confidential, and stored in an encrypted system.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This is a private skincare studio within a shared space with hair and nail professionals. I’m a holistic + corrective specialist focused on real skin results. While the vibe is calming, treatments are interactive. If you're seeking a silent spa escape, this may not be the right fit.
Do you understand that this is a private studio located in a shared space with other professionals (hair, nails, etc.), and some background noise may be present during your service?
Spa Wrap Size Preference:
Scent Preference/Aversions:
Please answer the following questions to the best of your ability.
What is your skin type? (Dry, Combo, Oily, Sensitive, Wise, Acne, Rosasea)
What are your skin concerns?
When was your last facial?
Have you had any reactions to skincare, cosmetics, treatments, et cetera?
Where do you shop for your skincare products?
What is your daily skincare routine?
What are your goals for your skin?
How often do you exercise/what kind of exercise do you enjoy?
How many hours of sleep to you get each night?
How often would you like to come in for facials?
Medical History- Please Check All That Apply:

Other
Medical History- Continued
Are you on any medications or topical prescriptions? If so, please specify.
Do you have any allergies? If so, please specify.
Have you had any major surgeries? If so, please specify.
What skincare products have you used?
Have you used retinol in the past 15 days? If yes, when was your last application?
Have you had any chemical peels, laser treatments or injectables in the last 30 days?
Questions/Anything you want me to know prior to your appointment?
Signature
Should be Empty:

Facial Consultation & Intake Form

Please answer the following questions to the best of your ability.