Consultant Client Intake Form
Client's Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (+92000) 000-0000.
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
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
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