The Real Glow Esthetics Client Intake Form

Client Intake Form
Client's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any of the following conditions? If yes, please select them:

Other
Skin condition

Other
How does your skin heal?

Other
How do you take care of your skin at home?
Do you consume alcohol?
Is there a chance you might be pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptives? ( Pills, IUD, Patch, etc)
Are you breastfeeding?
Do you consume caffeinated drinks?
Are you wearing any contact lenses?
Are you currently under any kind of diet?
Have you undergone any surgeries?
If yes, when?
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. The Real Glow Esthetics does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that The Real Glow Esthetics will not be liable if I withhold vital information and complications happen.

I release The Real Glow Esthetics and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty: