New Client Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Phone Number*

Area CodePhone Number

Date of birth*

Date

E-mail address *

example@example.com

Occupation*

Emergency Contact*

Do you prefer a quiet service?

YesNo preference

I have a table warmer. Do you prefer the you prefer the table warmer off during your visit?

Warm is perfectI get hot, off would be great

How would you describe your skin type?

What products do you use on a daily basis?*

What would you like us to work on?*

What treatments have you done before?*

If you've had any of the above treatments, when and where did you get them?

What are your main skin goals and concerns?*

What brands of skincare do you use?*

What makeup products are you currently using?*

Does your job require you to sit in front of a screen for long periods of time? (blue light exposure)*

Do you wax your face on a regular basis? If yes, when was the last time? *

Does your job and/or lifestyle require that you work or play outdoors?*

In the past 2 weeks have you:*

Been waxedUsed a tanning bedNone

How committed are you to incorporating Emerald's recommendations and advice in your skin journey?*

Are you currently pregnant, trying to get pregnant or breastfeeding?*

Are you currently under the care of a physician, dermatologist or healthcare professional? If yes, please explain*

Do you /have you ever used any retinol, Differin, Accutane, Retin-A or retinoid products? *

Do you wear sunscreen every day? Which one? Name and spf level *

Do you take any medications? If so, which ones?*

Do you have any allergies or sensitivities?*

Do you smoke or vape?*

Circulatory issues? Arthritis?*

Have you ever experienced a reaction to any of the following? Medicine, iodine, latex, pollen, food, fruit. Yes or no? If yes, please explain*

Do you have any other medical health issues not covered in this form?*

I understand, have read, and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary, and I release this company and/or skin care professional from liability and assume full responsibility thereof.

Please understand that no guarantees can be made and no refunds will be given for services rendered. If for any reason changes to your appointment need to be made, we ask that you provide at least 48 hours' notice. Failure to do so will result in applicable fees. More than two reschedules or cancellations per calendar year will require a nonrefundable deposit for booking future appointments.

By signing this agreement, I authorize Emerald Esthetics to charge the credit card on file for fees associated with cancellations, reschedules without adequate notice, or no-shows in accordance with the policies outlined above.

I also understand that according to insurance and to maintain a peaceful environment, children and additional guests are not permitted in the treatment room under any circumstances.

I understand and agree to the policies listed above *

Signature*

Date*

~~Please arrive to your appointment with a clean, makeup free face. Moisturizer and sunscreen is fine. If this is not your first appointment with me you do not need to fill out this form.~~

New Client Intake Form

Skin Questions

General Health

Policies