Consultant Client Intake Form

Consultant Client Intake Form
Client's Name

First Name Last Name
Gender

Male Female
Date of Birth

Month Day Year
Date
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Civil Status

Single Married Divorced Widowed
Occupation
Company Name
Do you have any of the following conditions? If yes, please select them:

Cancer Hypertension Hypotension Metal Implants Pacemaker or Defibrillator Diabetes Claustrophobia Heart Disease Thyroid Disorder Hysterectomy Hormonal Imbalance Epilepsy or Seizures Blush Easily HIV AIDS Hepatitis A/B/C Migraines/Headaches Depression/Anxiety Psoriasis Rosacea Eczema Bruise Easily Spinal Cord Injury Immune Disorder Lupus Keloid Scarring Blood Clot Disorder Skin Disease Fibromyalgia Menopause Circulation Disorder Varicose Veins Other
Skin condition

Normal Oily Dry Acne Other
How does your skin heal?

Fast Pigments Scars Slow Other
How do you take care of your skin at home?
How do you take care of your skin at work?
Do you consume alcohol?

Yes No
Are you pregnant?

Yes No
Are you trying or planning to be pregnant?

Yes No
Are you taking any contraceptive pills?

Yes No
Are you breastfeeding?

Yes No
Do you consume caffeinated drinks?

Yes No
Are you wearing any contact lenses?

Yes No
Are you currently under any kind of diet?

Yes No
Have you undergo any surgeries?

Yes No
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

Clear
Date Signed

Month Day Year
Date
Should be Empty:

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Consultant Client Intake Form

Terms & Conditions