Client Intake Form

Client Name

First NameLast Name

Occupation

Job Title

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

Please take a moment to answer the following questions

Is this your first facial?

What is the reason for your visit today?

Do you have any skin concerns you would like to address?

Are you currently under the care of a Dermatologist?

Are you now using, or have you ever used Accutane?

If yes, when and for how long?

Have you had skin cancer?

Do you have any allergies to cosmetics, food or drug?

Please specify (ex. Latex, shellfish, Witch Hazel, AHAs, dairy)

Are you currently taking any medications?

Please list

Are you taking birth control?

If yes, which one?

Are you pregnant?

What skin care products do you currently use?

Please specify Product Brands here (AM Routine/ PM Routine)

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

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 a 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 the services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in the future.

Client Signature

Date