Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
What areas of concern do you have regarding your skin:

Blackheads/WhitheadsAcne/BreakoutsExcessive Oil/ShineBroken CapillariesWrinkles/Fine LinesRedness/Burning/InflammationUneven Skin ToneDull/Dry SkinSun DamageRosaceaDark Spots/ HyperpigmentationEczemaDark Circles/ Tired EyesClogged PoresFlakey SkinOther
What skincare products do you use regularly?

CleanserTonerSerumMoisturizerSunscreenExfoliatorEye CreamFacial OilMaskOther
Have you have any of the following in the last 2-6 weeks?

LaserChemical PeelMicrodermabrasionDermaplaneTanning/SunburnBotox/FillersMicroneedlingFacial ThreadingOther
What is Your Skin Type?

NormalOilyDryAcneSensitiveNot sure
Do you have a current skin care routine?

YesNo
Do you wear Sunscreen?

YesNo
How often do you exfoliate?

1-2x per weekDailyOn occasionNever
Do you have any sensitivities or Allergies?
Are you currently using a Retinol/Retin-A/Tretinoin?

YesNo
Have you ever been on Accutane?

YesNoCurrently
Are you currently on blood thinners?

YesNo
Do you have a history of cold sores (HSV-1)?

YesNo
Are you taking any medications that is related to cosmetic or skin improvement?
Are you pregnant or breastfeeding?

YesNoN/A
Are you trying or planning to be pregnant?

YesNoN/A
Have you undergone any cosmetic surgery on the face in the past 2 weeks?

YesNo
Do you consent to extractions?

YesNo
Do you consent to photos for progress tracking?

YesNo
Music Preference:

The Skin Prayer Curated PlaylistSpa Style/Meditation MusicNo preference
Heated Bed?

YesNoNo preference
Massage pressure:

LightMediumFirmNo 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

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Terms & Conditions