Facial Treatment - Client Intake Form

Client Intake Form

Facial Service
Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you wish to have a silent appointment?
Your Health

Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify:
Have you had any health problems in the past or present?
If yes, please specify:
Do you have ANY allergies?
If yes, please specify:
List any medications, supplements, vitamins, diuretics, Accutane, etc that you take regularly?
Do you smoke?
Do you exercise regularly?
Do you follow a restricted diet?
Do you have metal implants, a pacemaker or body piercings?
Do you wear contact lenses?
Do you sunbathe or use tanning beds?
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
Have you ever experienced claustrophobia?
Your Skin
What are your specific concerns / challenges with your skin?
What skin care products are you currently using on your face? Please check all that apply.
What skin care products are you currently using on your body? Please check all that apply.

Other
Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?
If yes, in the last month?
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
If yes, in the last six months?
Are you currently using any products that contain the following ingredients?
Have you ever experienced the following conditions on your skin?
What SPF sunscreen do you use on your face? Type n/a if not applicable.
What SPF sunscreen do you use on your body?
Do you have a tendency to redness?
Do you burn easily in moderate sunlight?
Do you receive Botox/Filler? If yes, when was the last time ?
Have you had any permanent makeup?
If yes, please specify where on your skin and when you had the service done:
Female Clients
Are you taking oral contraception?
Are you pregnant?
Are you lactating?
Are you planning a pregnancy?
Are you currently having or due for a menstrual cycle?
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
Do you wish to have any of these fragances for the diffuser during your appointment?
What music do you want to play during your appointment? You can also put anything, or send me a playlist you like!
What music genre/ artist/ type do you NOT want to play?
Should be Empty:

Client Intake Form

Your Health

Your Skin

Female Clients