Confidential Intake Form

AMORE SKINCARE

Client Intake Form
Date:*
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Phone Number*
Text number
Address:
City, State*
Zipcode*
Email Address*
example@example.com
Would you like to be added to our email list for specials and discounts?*

YesNo
Occupation*
Helps me to determine what environment your skin is exposed to
How did you hear about us?*
Do you have any of the following conditions? If yes, please select them:*

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Skin condition*

NormalOilyDryAcneOther
How does your skin heal?*

FastPigmentsScarsSlowOther
How do you currently take care of your skin?*
Do you consume alcohol?*

YesNo
Are you pregnant?*

YesNo
Do you consume caffeinated drinks?*

YesNo
Are you wearing any contact lenses?*

YesNo
Are you currently under any kind of diet?*

YesNo
Have you undergo any surgeries?*

YesNo
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. Amoreskincare does not sell, share, or resell information.

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

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

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 my
esthetician of any changes to the information listed on all the pages of this client intake form. I have
been informed of and understand the contraindications to the requested treatments and agree that
I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my
esthetician of any discomfort I may experience at any time during my treatment to allow them to
adjust accordingly. I agree to waive all liabilities toward my esthetician and "AmoreSkincare" for any
injury or damages incurred due to the misrepresentation of my health history.
Client Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

AMORE SKINCARE

Terms & Conditions