Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Phone Number
Email Address
example@example.com
Gender

FemaleMaleOther
Are you under 18?

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

Metal ImplantsPacemaker or DefibrillatorEpilepsy or SeizuresOpen WoundCold SoreHepatitis A/B/CHIV AIDSBlood Clot DisorderSkin DiseaseHormonal ImbalanceMigraines/HeadachesEczemaBruise EasilyBlush EasilyImmune DisorderCirculation DisorderDiabetesHeart DiseaseNoneOther
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.

Agree to have LED therapyEpilepsyLaser treatments - vision/eye irritationMedications that cause light sensitivityPhotosensitivityPrefer not to undergo this treatment
Skin condition

NormalOilyDryAcneBlackheadsBreakoutPigmentationFine line/ WrinklesAge spotsDullnessDark CirclesOther
How does your skin heal?

FastPigmentsScarsSlowOther
Are you?

PregnantBreastfeedingPlanning to be pregnant
How long ago was your last facial?
Have you undergo any facial surgeries recently?

YesNo
Are you wearing any contact lenses?

YesNo
How often do you wash your face with cleanser?

NoneDailyWeeklyMonthly
How often do you exfoliate?

NoneDailyWeeklyMonthly
How often do you use sunscreens?

NoneOnce a dayTwice a dayMore
How often do you apply moisturizer?

NoneOnce a dayTwice a dayMore
Have you had any of the following services within the last 3 months?

Chemical PeelMicro-needlingMicrodermabrasionLaser TreatmentOther
Have you had any of the following services within the last 2 weeks?

BotoxFillerNone
Please let us know your goal for this visit?
Terms & Conditions
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

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Terms & Conditions