Main Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Gender

MaleFemaleOther
Date of Birth

MonthDayYear
Date
Phone Number
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:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid or Excessive ScarringBlood Clot DisorderSkin InfectionFibromyalgiaMenopauseCirculation DisorderVaricose VeinsHerpes (Cold sores)Auto-Immune DiseaseOther
What are your concerns and goals?
Skin Type

NormalOilyDrySensitiveCombinationOther
How does your skin heal?

FastPigmentsScarsSlowOther
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?

Very consistentSomewhat consistentNot very consistentI have no idea what I’m doing Haylie I need you!
Do you consume alcohol?

YesNo
Do you smoke?

YesNo
Have you used Retin-A, or any exfoliating products or received any skincare treatments within the last 7-14 days?

YesNo
Are you pregnant?

YesNo
Are you trying or planning to be pregnant?

YesNo
Are you taking any contraceptive pills?

YesNo
Are you use any prescribed topicals?(Ex. Tretinoin)

YesNo
Are you breastfeeding?

YesNo
Do you consume caffeinated drinks?

YesNo
Are you wearing any contact lenses?

YesNo
Are you currently under any kind of diet?

YesNo
Have you undergo any surgeries?

YesNo
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

Clear
Date Signed

MonthDayYear
Date
Practitioner Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Terms & Conditions