Client Intake Consultation Form (1)

Name

Date of Birth

Date

Address

Cell for Texting

Format: (000) 000-0000.

E Mail

example@example.com

Okay to e-mail?

Emergency Contact

Emergency Contact Telephone

Format: (000) 000-0000.

Your Skin Goals and Concerns

Your Skin Type:

What skin products are you currently using?

What makeup products are you currently using?

Does your job and lifestyle require that you work/playoutdoors?

Do you wax your facial skin on a regular basis?

If yes, when was the last time?

Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments? If yes, was it within the last month?

Are you using Benzoyl Peroxide?

Do you have any allergies or sensitivities?

Have you ever experienced an allergy or reaction to any of the following:

Do you have any of the following health issues?

Do you take any medications?

Do you take Accutane?

Are you a member of BBB?

I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.

Signature

Date