New Client Facial Intake Form
Thank you for choosing Queen Esthetics!
All questions listed contribute to collecting knowledge on underlying skin conditions and concerns. Please answer as thoroughly as possible. All responses will remain confidential.
Personal Information
Full Name
*
First Name
Last Name
Age
Gender
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Occupation
Appointment Date and Time
*
Please check the conditions that apply to you:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Claustrophobia
Epilepsy
Acne
Eczema
Seborrhea
HIV/AIDS
Varicose veins
Psoriasis
Dermatitis
Do you currently have any cold sores or open lesions? (This will result in an immediate reschedule)
*
Yes
No
Medical History
Are you currently taking any medications, supplements or vitamins?
*
Yes
No
If so, please list medications below. (If none, say "N/A")
*
Are you using any of the following medications?
Retinoids
Benzoyl Peroxide
Hydroquinone
Accutane
Cortisone creams
Glycolic acid, salicylic acid, lactic acid
Other
Do you have any known allergies? (If none, say "N/A")
*
Are you currently pregnant or trying to get pregnant?
*
Yes
No
Not Sure
Have you ever used acne medication?
*
Yes
No
If so, approximately how long ago?
Have you recently received Botox, Restylane, or Collagen injections in the last 6 months?
*
Yes
No
Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?
*
Yes
No
Unsure
Are you currently on birth control?
Yes
No
Do you have any of the following (pacemakers, metal implants, braces, etc.)
*
Yes
No
Have you had chemical peels, laser or microdermabrasion done within the past 30 days?
Yes
No
Have you had a facial or brow waxing within the past two weeks?
Yes
No
Skin History
Have you ever received a facial treatment?
Yes
No
What is your skin type?
Oily
Combination
Dry
Normal
Unsure
Do you have sensitive skin?
Yes
No
Unsure
What is your current skincare regimen? What products do you currently use? If you do not have a current regimen, please say "N/A"
Approximately how much water do you consume on a daily basis?
What are your skin concerns?
Breakouts/Acne
Fine lines/ Wrinkles
Uneven skin tone
Dry/ Dull Appearance
Excessive Oil/ Shine
Redness/ Sensitivity
Any additional concerns you would like me to be aware of?
Do you want to emphasize skin education or relaxation for your first visit?
Please Select
Education
Relaxation
Both
Request for Silent Appointment: Please choose this option if you would prefer no talking throughout the entire duration of your facial service.
I would like a Silent Appointment
Your appointment, your choice in music! Feel free to leave a few of your favorite artists below. If you do not have a preference, please say "N/A" :)
By signing below, you agree to the following: I consent to the scheduled facial treatment. I have completed this form truthfully and to the best of my knowledge. I agree to inform the esthetician of any changes in the above information. I agree to waive all liabilities towards my esthetician for any injury or damages incurred due to any misrepresentation of my health history.
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