Facial Treatment - Client Intake Form

Client Intake Form
Name

First Name Last Name
Date of Birth

Month Day Year
Phone Number
Please enter a valid phone number.
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? *

Yes No
If yes, please specify:
Have you had any health problems in the past or present? *

Yes No
If yes, please specify:
Do you have any allergies? *

Yes No
If yes, please list them:
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you’ve taken in the last 6 months *
Do you smoke? *

Yes No
Do you exercise regularly? *

Yes No
Do you have metal implants, a pacemaker or body piercings? *

Yes No
Have you ever experienced claustrophobia? *

Yes No
What aromas do you prefer?
Ex: lavender, eucalyptus, sage, citrus, seasonal, lemon grass, etc. . .
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. *

Soap Cleanser Toner Moisturizer Masque Exfoliator Eye Products None
Have you had a chemical peel, or resurfacing treatment in the last month? *

Yes No
Have you recieved Botox, Restylane, or collagen injections in the last six months? *

Yes No
Are you currently using any products that contain the following ingredients? *

Glycolic acid Lactic acid Retin-A, Renova Hydroxy acid products Vitamin A derivatives (ie., Retinol) None
Do you ever experience burning, itching or stinging sensations on your skin? *

Yes No
Do you have a tendency to redness? *

Yes No
Female Clients Only
Are you pregnant? *

Yes No
Are you lactating? *

Yes No
Questions to discuss every visit
have you experienced any flu like symptoms in the last 7 days

Yes No
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that i do not have any conditions that would make the requested treatment unsuitable. I will inform the technician of any discomfort i may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history. *

Clear
Should be Empty:

Client Intake Form

Your Health

Your Skin

Female Clients Only

Questions to discuss every visit