New Client Intake Form
Client Information
First Name
Last Name
Gender
Male
Female
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
Emergency Contact
Full Name
Relationship
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Please take a moment to answer the following questions
Do you have any allergies, including to any latex, cosmetics, or medicines?
Yes
No
If yes, please specify:
Have you been under the care of a physician or dermatologist within the past year?
Yes
No
If yes, please explain:
Are you pregnant?
Yes
No
Please check if you are affected by or have any of the following
Asthma
Cardiac Problems
Depression
Herpes
Fever Blisters
Anxiety
Epilepsy
Skin Disease
Hepatitis
High Blood
Pressure
Sinus Problems
Immune Disorders
Lupus
Eczema
Hysterectomy
List any medical or health problems you have had in the past or present.
Skin Care History
Please take a moment to answer the following questions
Have you had chemical peels, microdermabrasion, or resurfacing treatments in the past month?
Yes
No
If yes, please describe:
Have you received Botox, Collagen injections, or Restylane in the last 6 months?
Yes
No
If yes, please clarify:
How would you describe your skin?
Normal
Dry
Oily
Sensitive
Other
What skin care products do you currently use?
Cleanser
Sunscreen
Toner
Eye Cream
Spot Treatment
Chemical Peel
Vitamin C Serum
Moisturizer
Other
What are some of your skin care concerns?
List any medications you use regularly, including supplements, vitamins, Accutane, prescription drugs, creams, or any other skin care medications.
Terms & Conditions
I agree with
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 these treatments should not be construed as a substitute for medical examination, diagnosis, or treatment & that I should see a physician, or other qualified medical specialist for any mental or physical ailment that I am aware of.
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.
The payment policy and cancellation procedures.
I also understand that;
The answers I have have given are correct to the best of my knowledge and that I have not withheld any information that may be relevant to my treatment.
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
Submit
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