Esthetician Client Intake Form

Client's Name

First NameLast Name
MaleFemaleNon-Binary
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedDivorcedWidowed
Occupation
Company Name
CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
NormalOilyDryAcneOther
FastPigmentsScarsSlowOther
How do you take care of your skin at home?
How do you take care of your skin at work?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If "Yes" please detail which type of diet. (e.g. vegetarian, pescatarian, vegan, keto, etc.
YesNo
If "Yes" please indicate which type of surgery.
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
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

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Date Signed

MonthDayYear
Date

My Products

Should be Empty:

Terms & Conditions

Payment Methods