Client Intake Form

Client's Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email Address

example@example.com

Gender

Are you under 18?

Do you have any allergies? If yes, please mention them:

Do you have any of the following conditions? If yes, please select them:

LED light therapy is recommended for all facial treatments to restore your skin from acne, irritation, pigmentation, also to deliver serum/collagen/elasticity effectively. Please let us know of any reasons/objections you may have to the LED treatment.

Skin condition

How does your skin heal?

Are you?

How long ago was your last facial?

Have you undergo any facial surgeries recently?

Are you wearing any contact lenses?

How often do you wash your face with cleanser?

How often do you exfoliate?

How often do you use sunscreens?

How often do you apply moisturizer?

Have you had any of the following services within the last 3 months?

Have you had any of the following services within the last 2 weeks?

Please let us know your goal for this visit?

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. Before and after photos are taken both for personal and advertising use. I am okay with my photos being shared on social media. (If you decide otherwise, these photos will be confidential and only yourself and us will see these photos). I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

Client Signature

Date Signed

Date

Client Intake Form

Terms & Conditions