Facial Intake Form

Facial Intake Form
Client's Name

First NameLast Name
Gender

Other
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
Civil Status
Occupation
Company Name
We give a $10 referral credit to those who referred you. How did you hear about us?
Do you have any of the following conditions? If yes, please select them:

Other
Skin condition

Other
How does your skin heal?

Other
How do you take care of your skin at home?
How do you take care of your skin at work?
Do you consume alcohol?
Are you pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptive pills?
Are you breastfeeding?
Do you consume caffeinated drinks?
Are you wearing any contact lenses?
Are you currently under any kind of diet?
Have you undergone any surgeries?
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. 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 also give consent to my esthetician to take pictures and videos to use for marketing purposes such as social media and portfolios.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Facial Intake Form

Terms & Conditions