Client Intake Form
Client Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Please take a moment to answer the following questions
Are you presently taking any medications?
No
Yes
Please list all
*
Medical History
Rows
Yes
No
Diabetes
Blood Clot Disorder
Epilepsy or Seizures
Hormone Disorder
Anemia
Autoimmune Disorders
Cancer
HIV/AIDS
Migranes/Headaches
Skin Disease
Rosacea
Eczma
Psorasis
Staph Infection/MRSA
Herpes Simplex (Cold Sores)
Keloid Scarring
Do you have any allergies to cosmetics, food or drug?
Yes
No
If so, specify.
Are you currently taking any supplements or vitamins? If so, list below. Or message me a picture.
What are your current skin concerns
Rows
Select all that apply
Acne
Texture
Aging
Wrinkles
Discoloration
Redness
Dark Spots
Clogged pores
Scarring
Dullness
Dryness
Oilness
List any other skin concerns and/or what your skin goals are?
Are you looking to come in consistently to meet your skincare goals? (Every 4-6 weeks is recommended)
Yes
Possibly
No
What does your skin care routine look like? Or message me a picture of your full routine.
Rows
List Specific Product Name
Cleanser
Toner
Serums
Exfoliant
Moisturizer
Sunscreen
Other
Are you looking to get new homecare products to help reach your skin goals?
Yes
Possibly
No
Have you had any skin treatments in the past? Facials, Chemical Peels, Microdermabrasion, Microneedling, Extractions, Laser Treatments.
Yes, within the last 3 months.
Yes, within the last year.
No
If so, what treatments and when?
What’s your workout/exercise schedule like?
6-7 days per week
4-5 days per week
2-3 days per week
No current schedule
Have you gotten any injections in the past 2 weeks? Botox, Dysport, Fillers, etc.
Yes
No
Have you gotten any hair removal services in the past 30 days on your face? Such as Waxing, Sugaring, Laser Hair Removal, etc.
Yes
No
Have you used a Retin-A, Tretinoin, Adapalene, Accutane, Spirnolactane, Active Acids in the last week?
Yes
No
If so, specify product and duration.
Are you pregnant, nursing or trying to conceive?
Yes
No
Do you smoke and/or vape?
Yes
No
Do you see a dermatologist regularly?
Yes
No
Are you on any form of birth control? Including pills, IUD, ring, nexplanon, shot, etc.
Yes
No
If so, specify what kind.
Do you prefer a silent appointment/treatment?
Yes
No
No prefrence
Are you okay with photos/videos being posted on social media accounts?
Yes
No
Yes, but block out eyes
Terms and Conditions
You agree that all of my information you have shared above will be confidential and only ever talked about during the treatment. You have answered honestly and correctly about the information you have input. If you experience any pain or discomfort during the session, you will immediately inform the esthetician. You further understand that the facial should not be constructed as a subsite for medical examination or diagnosis.
*
I understand and agree to the terms and conditions
Policies
Your card must be on file to receive an appointment. If you reschedule or cancel your appointment within 24 hours you will be charged $25 to the card on file. If you no-show the appointment you will be charge 50% of the appointment cost to the card on file. If the card is declined, payment must be necessary to book any other appointment in the future. Clients under the age of 18 are required to have a parent/guardian attend during the appointment. Failure to follow these policies will result in not be able to book any future appointments.
*
I understand and agree to the policies.
Client Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: