Service Intake Form

Service Intake Form

Please Complete This Form No Later Than 24hrs of Booking Service, not Prior To Service. Services will not be booked if deposit sent through invoice, nor Service Intake Form is not received.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Civil Status
Occupation
What Service would you like to book?
Face and Body?
Do you have any of the following conditions? If yes, please select them:

Other
Skin condition

Other
How does your skin heal?

Other
What is your skin concern?
Have you recently experienced any injuries or been under surgery in the past 6 months? If Yes, Please give a brief description.
How do you take care of your skin at home?
How do you take care of your skin at work?
Do you consume alcohol?
Are you pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptive pills?
Are you breastfeeding?
Do you consume caffeinated drinks?
Are you wearing any contact lenses?
Are you currently under any dietary restrictions?
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Service Intake Form

Terms & Conditions