CLIENT INTAKE FORM
This form will allow me to get to know you and your skin better. This allows and helps me to provide you attentive service and customize it to your specific skin needs! Please complete prior to your scheduled appointment.
PERSONAL INFORMATION
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Occupation
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Medical History
Please list any medical conditions or health problems you have had in the past and present :
Please list any medications you us regularly, including any supplements, vitamins, accutane or other skin care medication:
Do you have any ALLERGIES, including to cosmetics, latex or medicine? If yes, please describe:
Do you consume alcohol?
Yes
No
Do you smoke?
Yes
No
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
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Skin Care History
Do you or have you used in the last 3 months RetinA, Renova, AHAs, or retinol/ vitamin A derivative ? If Yes, please describe:
Have you had chemical peels, microneedling, microdermabrasion or resurfacing treatments in the past month?
Have you had any Botox, fillers in the past 6 months?
Yes
No
What is your skin type?
Normal
Dry
Oily
Combination
What skin care products are you currently using at home?
What are your specific CONCERNS/CHALLENGES with your skin?
What are your skin GOALS?
Photos/video may be taken during your treatment for the purpose of tracking progress, transformations to keep in your client file. Photos may be used to continue promotional, educational, informative purposes. Do you consent to photos/videos of your treatment being shared?
Yes
No
Signature
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Continue
Should be Empty: