New Client Intake Form

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Email*

example@example.com

Instagram Username Handle*

What is your occupation?

Emergency Contact Name & Mobile*

How did you hear about me?

If Referral, please list name

What are your skincare goal you would like to achieve?*

What are your specific concerns / challenges with your skin?*

Please feel free to go into more detail

Have you ever had a facial or skin treatment before? *

YesNo

If Yes, when, what treatment and how long ago?

What's something you mainly want to focus on during your facial? E: Relaxation, Extraction, Everything/Experience as whole :) Please let us know so we can best accommodate your need!*

During the facial treatment do you prefer to be quiet or to chat*

Yes, prefer a quiet experience to relax and enjoying the treatmentNo, I don't mind chattingI don't care

What skin type do you think you have?*

How does your skin heal?*

FastSlowPigmentScars

Exposure of the sun?*

NoneLightModerateExercise

Does your skin bruised easily?*

YesNo

Do you have a tendency to redness?*

YesNo

Have you ever used acne medication?*

YesNo

If Yes, How long ago?

Do you ever experience these conditions on your skin?*

NoneFlakinessTightnessObvious Dryness

What skin care products are you currently using on your face? Please check all that apply.*

Preferred Brand(s)

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you received any of these facial services in the last 14 days? *

Electrolysis / LaserBotox / Dermal Fillers / Facial InjectablesNone

If yes, please confirm last date

Date

Please check that applies to you currently or in the past:*

Any known allergies? (aspirin, nuts, fruits, shellfish, essential oils etc)*

YesNoOther

If yes, please give details

Any recent surgery?*

NoYes

Do you take any dietary / health supplements? If yes, please list

YesNoOther

Have you currently taken any prescription / over the counter medications*

YesNo

If yes, please give details

What is your daily water intake (glasses / litres)*

How many cups of caffeine do you drink daily?*

1-34 or moreNone

Average alcohol consumption per week?

Have you ever experienced claustrophobia?*

YesNo

Do you exercise frequently?*

YesNo

Do you sleep well?*

YesNo

Do you smoke?*

YesNo

Do you follow a restricted diet?*

YesNo

Do you?*

Please rate your stress level*

LowMediumHigh

Do you manage stress well?*

YesNo

Are you using hormonal contraception (Birth Control)?

YesNoN/A

Are you pregnant or trying to become pregnant?

YesNoRecently had a baby/breastfeeding

Are you breastfeeding/nursing

YesNo

Do you have regular periods?

YesNo

Any menopause issues?

YesNoN/A

Do you have a diagnosed hormonal imbalance?

YesNo

Is there any other information you would like to make your esthetician aware of? If yes, please give details:

Acknowledgement and Waiver

Pre Facial Advice:

Please avoid the use of any exfoliants 7 days before your appt.
Botox/filler injections must be done two weeks before your facial.

Post Facial Advice:

Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds).
If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30.
Facial massage, chemical peels, enzyme peels, microcurrent, and radio frequency may cause temporary redness/pinking of the skin; this is a normal and positive outcome that indicates an increase in bloodflow as a result of the treatment. Otherwise, all pinking should go away in a few hours.
If you have any concerns, please let me know prior to the treatment. Please keep in mind that you may experience breakouts following the facial. Because the facial is so stimulating, it brings all of the pimples to the surface, it's all part of the healing process!
Maintain a simple skin care routine for the next three days. A gentle cleanser, moisturizer, and an SPF of 30 or higher are required.
Exfoliating ingredients and products, as well as retinol, should not be used within 7 days of your service because over-exfoliation can cause irritation or further sensitivity.
DO NOT PICK THE PEEL or SCRATCH your skin as it may cause damage or compromise your results. We cannot guarantee absolute results because individual reactions to treatment vary. By choosing to receive treatment, you acknowledge and accept responsibility for any potential outcomes or reactions that may occur.
We encourage open communication and will do our best to address any concerns you may have throughout your treatment. We want you to understand that we put our clients' safety and well-being first. Please be assured that we are fully committed to maintaining the highest level of care and safety.

Do you give Adore Skin Studio permission to post photos/short video clips of you on their social media?*

YesNo

CLIENT DECLARATION: I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes 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. I understand I must communicate any new changes to my health assessment form to my esthetician. I understand that redness and other reactions may occur from facial treatments. If I experience any discomfort during the treatment I will inform my esthetician immediately, so that the products/techniques can be adjusted. The treatments I receive here are voluntary and I release the therapy from liability and assume full responsibility thereof. *

New Client Facial Intake Form

Skin History

Your Medical History

Lifestyle

Females Clients