New Client Intake Form
Name
*
First Name
Last Name
Address
*
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Okay to e-mail?
Yes
No
Emergency Contact
*
Phone Number
*
Format: (000) 000-0000.
Your Skin Goals and Concerns
*
Your Skin Type
Normal/Combo
Oily
Sensitive
Dry
Mild Acne
Moderate Acne
Mature & Aging
What skin products are you currently using?
What makeup products are you currently using?
Does your job and lifestyle require that you work/play outdoors?
Do you wax your facial skin on a regular basis?
Yes
No
If yes, when was the last time?
Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments?
Yes
No
If yes, was it within the last month?
Yes
No
Are you using Retin-A?
Yes
No
Are you using Benzoyl Peroxide?
Yes
No
Do you have any allergies or sensitivities?
Have you ever experienced a reaction to any of the following?
Cosmetics
Medicine
Iodine (shellfish)
Latex
Pollen
Food/fruit
Animals
Fragrance
Alpha hydroxy acids
Sunscreens
Do you have any of the below health issues? (Check all that apply)
Cancer
Chemotherapy
Circulatory issues
High blood pressure
Arthritis
Hysterectomy
Hormonal imbalances
Thyroid
Diabetes
Pregnant
Lactating
Planning to be pregnant
Psoriasis
Recent surgeries
Cold Sores
Eczema
Other
Do you take any medications?
Accutane?
Antibiotics?
Birth Control?
*
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability.
Date
-
Month
-
Day
Year
Submit
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