CLIENT INTAKE FORM

FACIAL CLIENT INTAKE FORM
APPOINTMENT DATE

MonthDayYear
Date
APPOINTMENT TIME
NAME
DATE OF BIRTH
GENDER
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
PHONE

Area CodePhone Number
What are your long term skin goals?
What are your areas of concern?
What are your goals for today's treatment?
Have you ever had professional skin care treatments previously?
If yes, please explain
What skin care products do you use presently?
MEDICAL INFORMATION:
Are you presently using (or used in the past) Azlex, Differin, Renova, Retin-A. Tazarac, Glycolic or Alpha Hydroxy Acids?
If yes. when and for how long?
Are you now using or have you ever used Accutane?
Please list any allergies you have
List all medications you are taking: (including OTC drugs. vitamins etc)
Have you ever had any of these conditions ? If NONE apply, please write "NONE" below
- Citrus Allergy
- Eye Infections
- Sulfur Allergy
- Autoimmune Disease
- Heart Disease
- Sciatica
- Hysterectomy
- Pregnancy
- Watery eyes
SKIN CARE HISTORY:
Select your skin type:
Have you ever had chemical peels. laser or microdermabrasion?
If yes, when and how long?
Have you used an acne medication?
If yes, when and which drug?
Do you ever experience a burning or itching sensation on your skin?
Do you ever experience oily shine during the day?
Any recent tanning bed or sun exposure that changed the color of your skin?
Have you experienced Botox, Restylane or Collagen injections?
If yes, please explain.
What concerns do you have with your skin?

Other
Explain your skin goals in detail
HEALTH HISTORY:
Please list any and all medical conditions you may have.
Are you currently under a dermatologist or other physician's care?
If yes, please explain
Within the last year. have you been undergone any surgeries?
If yes, please explain
FOR FEMALE CLIENTS:
Are you taking any birth control pills?
If yes. please specify
Are you pregnant or breastfeeding?
If yes, please explain
Is there anything else that should be known before starting your treatment?
I have read the above information and have given an accurate account of the questions. If have any concerns I will address these with my esthetician before the service. 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 nature. I give permission to my esthetician to perform the facial service and will not hold the esthetician nor Dream Beauty Loft, LLC accountable for any liability that may result from this treatment. I understand that the information herein is to aid the therapist in giving better service and is completely confidential.
Client Name
Client Signature
Should be Empty:

FACIAL CLIENT INTAKE FORM

MEDICAL INFORMATION:

SKIN CARE HISTORY:

HEALTH HISTORY:

FOR FEMALE CLIENTS: