Main Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Gender

Other
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
What was your last facial treatment? What changes have you noticed?
Do you have any of the following conditions? If yes, please select them:

Other
What are your concerns and goals?
Skin Type

Other
How does your skin heal?

Other
In the order in which you use them, list your current Morning skincare routine:
In the order in which you use them, list your current Night skincare routine:
Do you use any skincare tools at home? If so, what? (Ex. Cleansing devices , tinkle razors, Gua Sha stones)
How consistent are you with your skincare routine?
Do you consume alcohol?
Do you smoke?
Have you used Retin-A, or any exfoliating products or received any skincare treatments within the last 7-14 days?
Are you pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptive pills?
Are you use any prescribed topicals?(Ex. Tretinoin)
Are you breastfeeding?
Do you consume caffeinated drinks?
Are you wearing any contact lenses?
Are you currently under any kind of diet?
Have you undergo any surgeries?
What medications are your currently taking?
What supplements or vitamins are you taking?
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 understand that all purchases are final and non-refundable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
Practitioner Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Terms & Conditions