Facial Client Intake Form

Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
Date Of Birth
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
How did you hear about us?
What type of skin do you have? (Check all that apply)
What skin concerns do you have? (Check all that apply)
Other
Have you been under the care of a dermatologist within the past year?
Any chance of pregnancy?
Do you have any allergies?
Please list any medicines or supplements you currently take
What products are you currently using?
Do you currently or have you used in the last 3 months Retin-A. Renova, AHA's or Retinol/Vitamin A derivative products?
If yes, please describe
Have you received Botox, Restylane or Collagen injections in the last 6 months?
If yes please describe
Are you comfortable being photographed or recorded during your treatment?
I have completed the Confidential Consent form accurately. / am aware that / cannot receive treatment if / don't qualify because of my condition. The information contained in this informed consent was explained to be using terms I could understand, and all of my questions and concerns have been answered. / agree to follow up the esthetician at home-post procedure treatments for the time it is advice. I hereby release the esthetician, from any and all damage or injury that may result from the treatment / received. All of the information provided to the esthetician has been true and correct. The esthetician has provided the information necessary for me to have made the informed decision to proceed with the treatment(s I clearly understand the above information.
Client's Signature
DateAddress

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: