Client Intake Form

Client Intake Form

De Novo Aesthetics
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please take a moment to answer the following questions
Please tell me your skincare goals/concerns?
How serious are you about reaching your skincare goals?
Normal (no visible lines or blemishes)Combination (oily and dry, hormonal breakouts)Acne (cystic or nodules)Sensitive (redness, often irritated)Oily (enlarged pores, excessive oilDry (dull, visible lines and wrinkles)
CleanserTonerSerumEye CreamSpot TreatmentMoisturizerSunscreenVitamin C SerumFace OilRetinoidsOther
Please specify other:
EczemaPsoriasisRosaceaNone
YesNo
YesNo
Please list*
LatexAspirinPollenShellfishFruitsSeaweedLidocaineSunscreenTree nutsDairyBenzoyl PeroxideFragrance/oilsNone
WaxingThreadingLaserNone
YesNo
YesNo
YesNo
If yes, please specify
Have you received botox or fillers in the last 2-4 weeks? If so, please list the date.
YeaNo
HighModerateLow
Wear contactsHave metal implants/screwsConsume alcoholUse tanning bedsHave pacemakerSmokeConsume caffeine
AsthmaCardiac ProblemsDepressionHerpesFever BlistersAnxietyEpilepsySkin DiseaseHepatitisHigh BloodPressureSinus ProblemsImmune DisordersLupusEczemaHysterectomyHIV/AIDSHormonal ImbalancesOther
Please specify other:
YesNo
I acknowledge that I must adhere to De Novo Aesthetics, LLC policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of a package or 50% of the total service cost. I acknowledge that ANY no show will result in the loss of a package or 100% of the total service cost. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “No-show” policy.
Signature
Date

MonthDayYear
Date
I agree with If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I understand that; The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future. I also understand that the Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which facial treatments are contraindicated. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments and release De Novo Aesthetics, LLC and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
I give full consent to De Novo Aesthetics, LLC to use any photos taken, before, during, or after treatment to be used in any and all marketing and social media content.
Client Signature
Date

MonthDayYear
Date
Should be Empty: