Client Intake Form
Client Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Were you referred by anyone?
Please take a moment to answer the following questions
Please Check All That Apply
Acne
Arthritis
Diabetes
Eczema
Epilepsy
Fever Blisters
Heart Conditions
Hepatitis
High Blood Pressure
Low Blood Pressure
Lupus
Sinus Infection
Surgery
Psoriasis
Rashes
Seborrhea
Shingles
Skin Cancer
Hyper/Hypo Thyroid
Warts
Other
Are you presently taking any medications?
Yes
No
Please list
*
Have you had skin cancer?
Yes
No
Are you pregnant?
Yes
No
Are you taking oral contraceptives?
Yes
No
Do you have any allergies to cosmetics, food or drug?
Yes
No
If yes, please specify:
What skin care products do you currently use?
Cleanser Oil/Balm
Facial Cleanser
Bar Soap
Facial Scrub/Exfoliants
Chemical Exfoliator
Toner
Antioxidant Serum
Hydrating Serum
Eye Cream
Spot Treatment
Moisturizer
Sunscreen
Face Oil
Other
If you're interested in corrective treatments, list the specific product and brand name you use and this will help me in helping your skin care goals.
Have you used Retin-A, Renova, Accutane, Adapalene, Differen, BHAs, Glycolic/Lactic/Mandelic Acids, Retinol, or other Vitamin Products?
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Have you received Botox, Juvederm, Restylane, or Collagen injections within the last 6 months?
Yes
No
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last 30 days
Yes, within the last 3 months
Yes, within the last year
No
Have you been under the care of a dermatologist within the past year?
Yes
No
If yes, please explain:
Have you had any type of facial hair removal within the last 30 days?
Waxing
Threading
Dermaplaning
Shaving
Electrolysis/Laser
Depilatory Cream
Other
What concerns do you have regarding your skin?
Acne/Breakouts
Blackhead/Whiteheads
Clogged Pores
Dryness
Hyperpigmentation/Sun Damage
Excessive Oil/Shine
Redness
Rosacea
Scarring
Fine Lines/Wrinkles
Sensitivity
Other
I agree with
I understand, have read and completed this questionnaire truthfully. That this constitutes and supercedes any previous verbal or written disclosures.
I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.
If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort.
I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment.
I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.
I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so.
I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session.
Also I understand that;
The services offered are not substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in future
Client Signature
Date
-
Month
-
Day
Year
Date
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