New Client Intake Form

New Client Intake Form

SKIN BY BRIN
Client Name

First NameLast Name
Date of birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please take a moment to answer the following questions
Please check if you have any of the following:

PsoriasisCancerRosaceaAuto Immune DisorderEczemaCold SoresHormone ImbalanceDermatitisHigh Blood PressureEpilepsy/SeizuresSinus ProblemsPace Maker or DefibrillatorPregnant/BreastfeedingMetal ImplantsMenopause
If you have any of the following, please explain:
Please list all current medications you are taking both oral and topical:
Please list all and any allergies:
Are you currently using Retinol?

YesNo
If yes, when was the last time you used it:
Are you currently on Accutune (Isotretinoin) or have within the last year?

YesNo
Are you currently Pregnant?

YesNo
Have you had any Botox, Filler or any permanent cosmetics done in the past two weeks?

YesNo
What are your skincare goals for today and for future appts? You can select multiple options.

HydrationAnti-Aging/Address Fine Lines & WrinklesInflamed AcneScarring & TextureHyperpigmentationSun DamageOily SkinBlackheads/Clogged PoresRelaxationI'm here for another service (Lash Lift, Brows)
What is your skin type?

NormalOilyDryCombo
Please list skincare services you have had done in the past:
Please list all the Skincare products you are currently using at home: (Cleansers, Serums, Moisturizers, Etc.)
Terms & Conditons:

I understand to the best of my knowledge that the answers I have given are true and accurate and I have not witheld any information that may be relevant to my treatment. I understand that my information given will be strictly confidential.

I understand that with any treatment given, there is a possibility of a negative reaction or result, and do not hold the Esthetician (Brinli Muse) liable.

I consent to before and after photos being taken of my skin to track progress and for marketing purposes.
Client Signature
Date

MonthDayYear
Date
Should be Empty: