Confidential Client Intake Form

Kasthetics Skincare

Confidential Intake Form
Personal Information
Client Name*

First NameLast Name
Birth Date*

MonthDayYear
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Occupation
Emergency Contact Name*

First NameLast Name
Emergency Contact Number *
Please enter a valid phone number.
Health & Medical History
Have you been to a Dermatologist in the last year? If yes, please explain:*
Have you received a facial before? If so, when was your last one?*
If you answered yes, what kind of treatment(s)
Hormone ImbalanceCancer/ Systemic DiseaseDiabetesHeart ProblemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisordersFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches/MigrainesCoid - 19NoneOther
Are you sensitive to candles or essential oils? *
NormalcombinationDryOilyUnsure
Estimated Daily Water Intake ?
Female Health*
For Female Clientele
FoodAnimalsFragrancePollenAHASSunscreenMedicationLatexOther
Have you been on or currently taking Accutane? *
Retin-A/ Renova/TretinoinRetinol/Vitamin A DerivativesAHA'sNoneOther
Have you received Botox, Restylane, or collagen in the last 6 months ? :*
Do you use any products for your skin at home ? If so please list below:
What is your goal for todays session?
Signature

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 Kasthetics Skincare of any changes in the above information.
Signature:*
Todays Date:*
Should be Empty:

Kasthetics Skincare

Personal Information

Health & Medical History

Signature