Facial Treatment - Client Intake Form

Client Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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?*

YesNo
If yes, please specify:
Have you had any health problems in the past or present?*

YesNo
If yes, please specify:
Do you have any allergies?*

YesNo
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?*

YesNo
Do you exercise regularly?*

YesNo
Do you have metal implants, a pacemaker or body piercings?*

YesNo
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.*

SoapCleanserTonerMoisturizerMasqueExfoliatorEye ProductsNone
Have you had a chemical peel, or resurfacing treatment in the last month?*

YesNo
Have you recieved Botox, Restylane, or collagen injections in the last six months?*

YesNo
Are you currently using any products that contain the following ingredients?*

Glycolic acidLactic acidRetin-A, RenovaHydroxy acid productsVitamin A derivatives (ie., Retinol)None
Do you ever experience burning, itching or stinging sensations on your skin?*

YesNo
Do you have a tendency to redness?*

YesNo
Female Clients Only
Are you pregnant?*

YesNo
Are you lactating?*

YesNo
Questions to discuss every visit
Do you give permission to your technician to take photos and short recordings of your service for documentation and marketing on social media platforms.

YesNo
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.*
Should be Empty:

Client Intake Form

Your Health

Your Skin

Female Clients Only

Questions to discuss every visit