New Client Skin Consult Intake Form

New Client Skin Consult Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Address
City
State
Zip
Mobile Phone
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Occupation
Email Address
example@example.com
Date of Birth

MonthDayYear
Date
Age
How would you describe your skin?

OilySensitiveNormalCombination
What is your hereditary background?
Which of the following best describes your skin type? (Please select one skin type number)

I Pale skin, blue/green eyes, blonde/red hair, always burns, never tansII Fair skin, easily burns, tans minimallyIII Light brown, burns moderately, tans graduallyIV Moderate brown, seldomly burns, always tans wellV Brown complexion, rarely burns, deep tanVI Dark Brown Complexion, rarely burns, deeply pigmentedOther
Have you ever received any procedures (ie. facials, LED, chemical peels, Dermaplanning, microdermabrasion, Laser Hair Removal, Esthetic Laser Treatment, RF Treatments, Microneedling, PRP, Facial Waxing/Threading/Microblading, or Eyelash/brown tint/permanent make up.)
What was the date of last treatment and how frequent?
Have you received any procedures that is not listed above? If yes, explain:
Have you ever had any of the following injectables or implants?

BotoxRadiusesPerlaneCollagenDysportJuvedermRestylaneSiliconeSculptraOther
If other, please state what kind, when did you receive and what body area:
What skin care products do you use on daily basis? (ie. Cleanser, Toner, AM Moisturizer, PM Moisturizer, Sunscreen, Corrective Serum, Facial Scrub, Mask, Eye Cream, Other?
If other, please state which:
What skin care products brands do you use and how often?
Are you currently taking birth control pills or have an IUD?

YesNo
Are you currently pregnant or breast feeding?

YesNo
Are you currently experiencing peri menopause or menopause?

YesNo
Are you currently undergoing any hormone therapies or taking any infertility drugs?

YesNo
If yes, please explain:
Please list if you are taking Current Medications (include over the counter)
Please list if you are taking Current Herbal Supplements and Vitamins
Please list allergies:
Please list daily habits and daily intake:
Do you have any other medical concerns that have not been covered in this form?
If yes, please explain:
What are your current top 3 concerns with your skin and what improvements would you like to see?
I authorize Vanities by Jay to take my photos regarding my experiences with them. I grant Vanitiesby Jay permission to use my photos on Facebook, Twitter, Instagram, and other social media platform. I allow Vanities by Jay to edit, alter, copy, or distribute the photos for social media advertising and marketing. I agree that the photos belong to Vanities by Jay. I understand that I will not receive any monetary compensation.

Yes, I authorizeNo, I do NOT authorize
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 here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Client Signature
Date

MonthDayYear
Date
Parent/Guardian Signature (If under age 18)
Date

MonthDayYear
Date
Esthetician/Practitioner Signature
Date

MonthDayYear
Date
Should be Empty: