Intake Form

Client Intake Form
Patient Data

Note: If something does not apply to you please insert or select "N/A"
Patient Name *

First Name Last Name
Age *
Birth Date *

Month Day Year
Occupation (Optional)
Gender *
Phone Number *
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Health Assessment
Have you ever seen a dermatologist? *

Yes No
Any diagnosed conditions(s)? If yes, please list them below: *
Are you smoking? (Tobacco Products/ e cigarettes) *

Yes No
Are you currently taking any medications? If yes, please list them below: *
Do you have any allergies? If yes, please list them below: *
Are you pregnant, breastfeed, or nursing? (Female) *

Yes No N/A
Are you on birth Control? (Female) *

Yes No N/A
Periodic acne flare-ups related to cycle? (Female) *

Yes No N/A
Skin Assessment
Skin Tone *

Uneven Skin Color Sun Damage Age Spots Freckles Broken Capillaries Rosacea
Firmness & Elasticity *

Wrinkle Deep Fine Lip Lines Crows Feet Nasolabial Lines Loss of Firmness/Elasticity
Texture *

Texture Acne Scarring Large Pores Black Heads Dry/Rough Skin Stretch Marks
Skin type *

Dry Normal Oily Combination Acne Prone
Are you wearing sun screen daily? *

Yes No
Have you ever had a facial treatment before? *

Yes No
Does your skin tend to tan or burn? *

Tan Burn
Rate your skin *

1

2

3

4

5

1 is Worst, 5 is Best
Are you currently using any skin care products? If yes, please list them below: *
If you could change 1 thing about your skin what would it be? *
Have had recent procedures done? If yes, please list them below with approximate dates: *
Procedures
Procedures You Are Interested In at Le Petit Spa? *

Consulation HydraFacial Collagen Induction Chemical Peels (PCA) Dermaplaning Microdermabrasion TLi LED Light Therapy LED Lightwave Therapy Le Petit-European Facial Banacne Facial Mommy-To-Be Facial Gentleman Facial Mini Facial Custom Facial
Would you like to add additional information we should know? (Optional)
Authorization
I understand my data will be strictly confidential. Le Petit Spa will not share this information. I confirm that all information given in this form is true, complete, and accurate. I understand the procedure and accept the risks. I assume all risks and outcomes of treatments and the use of products. I release my Esthetician, Le Petit Spa, its faculty, and/or its staff for any responsibility in case of accident, illness, or injury. I acknowledge that no assurance was offered about the outcome.
Patient Name *

First Name Last Name
Signature of the Patient *

Clear
Parent/Guardian Name

First Name Last Name
Signature of Parent/Guardian

Clear
Should be Empty:

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Client Intake Form

Patient Data

Health Assessment

Skin Assessment

Procedures

Authorization