New Client Intake Form

Client Name

First NameLast Name

Date of birth

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

How did you hear about The Skin Cafe?

Please take a moment to answer the following questions

Of the two options listed below, which applies to you most?

Have you ever had a facial before?

How would you best describe your skin type?

What are your current skin concerns?

What is your current relationship with skincare?

Any metal implants, body piercings or pacemaker?

Do you have any allergies or sensitivities? (I.e nuts, fruits, aspirin)

If your answer is no, type no in the response box.

What skin care products do you currently use?

Please list your current home care routine AM/PM with Brand Names. The more specific you are, the better I am able to tailor your treatment for you.

Have you been under the care of a Dermatologist within the last year? If so, what for? Were you prescribed Accutane, Tretinoin, Clindamycin, Retinols, or any medication, topical/oral?

If your answer is no, type no in the response box.

Have you received chemical peels, microdermabrasion, dermaplaning, laser, or any other resurfacing treatments? Please specify the treatment and how long ago.

If your answer is no, type no in the response box.

Do you wear contact lenses?

Are you presently taking any medications? (prescription/otc)

If yes, please list

Are you pregnant or lactating?

Have you had skin cancer?

Do you experience claustrophobia?

Please check if you are affected by or have any of the following

I have not received any facial injectables, filler/botox, laser hair removal, or laser treatments in the past 14 days.

I have discontinued the use of exfoliating products and any products that contain retinoids 3-5 days before my treatment.

I have not received any facial waxing/threading/hair removal within 72 hours.

I have no viruses, such as colds, flu, fever, cold sores, warts, bacterial infections or fungal infections.

I give The Skin Cafe NJ and Jacqueline Harris permission to take photo and/or video of me during my service to use for promotional purposes and to keep track of my progress in between treatments.

I understand that if I am late to my appointment, the treatment must be adjusted to stay within the scheduled time frame. I understand that after 15 minutes late to the scheduled appointment, I will have to reschedule my appointment.

I understand that The Skin Cafe accepts card, cash, Apple Pay, and gift cards purchased through the booking website. Paying with cash saves 3.5% on the total purchase.

I agree that 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 these treatments should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that the esthetician is not qualified to 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. Also 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 understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from the treatments performed.

I agree that the treatments I receive here are voluntary.

Signature

Date