Client Intake Form
Client's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
What areas of concern do you have regarding your skin:
Blackheads/Whitheads
Acne/Breakouts
Excessive Oil/Shine
Broken Capillaries
Wrinkles/Fine Lines
Redness/Burning/Inflammation
Uneven Skin Tone
Dull/Dry Skin
Sun Damage
Rosacea
Dark Spots/ Hyperpigmentation
Eczema
Dark Circles/ Tired Eyes
Clogged Pores
Flakey Skin
Other
What skincare products do you use regularly?
Cleanser
Toner
Serum
Moisturizer
Sunscreen
Exfoliator
Eye Cream
Facial Oil
Mask
Other
Have you have any of the following in the last 2-6 weeks?
Laser
Chemical Peel
Microdermabrasion
Dermaplane
Tanning/Sunburn
Botox/Fillers
Microneedling
Facial Threading
Other
What is Your Skin Type?
Normal
Oily
Dry
Acne
Sensitive
Not sure
Do you have a current skin care routine?
Yes
No
Do you wear Sunscreen?
Yes
No
How often do you exfoliate?
1-2x per week
Daily
On occasion
Never
Do you have any sensitivities or Allergies?
Are you currently using a Retinol/Retin-A/Tretinoin?
Yes
No
Have you ever been on Accutane?
Yes
No
Currently
Are you currently on blood thinners?
Yes
No
Do you have a history of cold sores (HSV-1)?
Yes
No
Are you taking any medications that is related to cosmetic or skin improvement?
Are you pregnant or breastfeeding?
Yes
No
N/A
Are you trying or planning to be pregnant?
Yes
No
N/A
Have you undergone any cosmetic surgery on the face in the past 2 weeks?
Yes
No
Do you consent to extractions?
Yes
No
Do you consent to photos for progress tracking?
Yes
No
Music Preference:
The Skin Prayer Curated Playlist
Spa Style/Meditation Music
No preference
Heated Bed?
Yes
No
No preference
Massage pressure:
Light
Medium
Firm
No preference
Is there anything specific you’d like me to know or share before your facial?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. 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
-
Month
-
Day
Year
Date
Print Form
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