Esthetician Client Intake Form

Intake Form

Help me get to know you so I can better serve you
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
NormalOilyDryAcneOther
FastPigmentsScarsSlowOther
How do you take care of your skin at home?
YesNo
YesNo
YesNo
YesNo
YesNo
1. What are your skin concerns?
2. If you could wave a magic wand what would your skin look like in one month?
3. Any special requests for today? (Extractions, hydration, relaxation, etc)
4. Is there anything I need to know before we get started? The more I know, the better your results. (Please List: allergies, sensitivities, pregnant, nursing, health issues, diabetic, medications, metal plates, cold sores, herpes, Retin A use or any topic products that might cause skin sensitivity).
5. What did you LOVE about your last facial, and what could you have lived without?
6. Do you prefer me talking and explaining each step of the service or do you prefer to relax quietly?
Yes talk to me about itNo, just here to relax
7. Anything else you want to share? I love learning about my clients as it helps me provide superior customer service.
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic 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.

I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.

I understand DV Beauty has a strict 24 Hour cancellation policy. In the event of a late cancellation/no show the fee is 50% of the service or services and the card on file will be charged.
Client Signature

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Date Signed

MonthDayYear
Date
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Intake Form

Terms & Conditions