SOCAL ESTHETIX

SOCAL ESTHETIX

SKIN CLIENT INTAKE FORM
Name

First NameLast Name
DOB

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT + PHONE NUMBER
OCCUPATION
Skin Concerns
What type of skin do you have?

Other
What areas of concern do you have regarding your skin?

Other
Allergies
Have you ever had an allergic reaction to any of the following?

Other
Aromas/ Accommodations
Which aroma(s) do you prefer? (Please select all that apply)
Is there anything I can do that could enhance your experience?
Do you require any additional accommodations?
Skin History

𝗣𝗹𝗲𝗮𝘀𝗲 𝘀𝗲𝗹𝗲𝗰𝘁 𝗮𝗹𝗹 𝘁𝗵𝗮𝘁 𝗮𝗽𝗽𝗹𝘆.

Rows	Yes	No
Recent surgery (general) in the last 6 months?
Recent surgery (cosmetic) in the last 6 months?
Recent cosmetic injections (botox, filler, ETC.)
Recent hair removal? (waxing, laser, electrolysis)
Are you under a doctors' care for skin issues?
Laser treatments, IPL within the last month?
Chemical peels within the last month?
Loss of skin sensation?
Recent sunburn?

Health Conditions
Do you have any of the following health conditions?

Other
Daily Medications
𝗣𝗹𝗲𝗮𝘀𝗲 𝘀𝗲𝗹𝗲𝗰𝘁 𝗮𝗹𝗹 𝘁𝗵𝗮𝘁 𝗮𝗽𝗽𝗹𝘆.

Other
Daily Skin Care (1x, 2x, Weekly, Varies)

What is your current regimen?
Cleanser
Frequency: blank Brand: blank
Toner
Frequency: blank Brand: blank
Serum/ Oil
Frequency: blank Brand: blank
Mask
Frequency: blank Brand: blank
Eye Cream
Frequency: blank Brand: blank
Moisturizer
Frequency: blank Brand: blank
SPF
Frequency: blank Brand: blank
Lifestyle

Rows	Yes	No
Do you sleep at least 6-8 hrs a night?
Do you smoke?
Do you have chronic stress?
Do you exercise regularly?
Do you use hormone replacement therapy?
Do you get daily UV exposure?
Do you drink more than 7 drinks of alcohol in a week?
Do you eat at least 3 servings of vegetables a day?
Is your intake of sugar more than 100 cals a day?
Do you drink more than 2 cups of caffeine a day?
Do you drink 8-10 glasses of water a day?
Do you take probiotics daily?
Do you take Vitamin D3 daily?
Do you take a multivitamin daily or omega oils?

If no to 6-8 hrs of sleep, how many?
If you had to give a stress level would you choose?
How many hours of uv exposure A DAY do you get?
Future Appointments/ Contact

Rows	Yes	No
May I call you at your phone number to confirm future appointments?
May I text you to confirm?
May I contact you via mail/email about future promotions and news?

Service Consent:
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 𝘁𝗵𝗲 𝗮𝗽𝗽𝗼𝗶𝗻𝘁𝗺𝗲𝗻𝘁 𝗰𝗮𝗻𝗰𝗲𝗹𝗹𝗮𝘁𝗶𝗼𝗻 𝗽𝗼𝗹𝗶𝗰𝘆. 𝗧𝗵𝗲 𝘁𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁𝘀 𝗜 𝗿𝗲𝗰𝗲𝗶𝘃𝗲 𝗵𝗲𝗿𝗲 𝗮𝗿𝗲 𝘃𝗼𝗹𝘂𝗻𝘁𝗮𝗿𝘆, 𝗮𝗻𝗱 𝗜 𝗿𝗲𝗹𝗲𝗮𝘀𝗲 𝘁𝗵𝗶𝘀 𝗶𝗻𝘀𝘁𝗶𝘁𝘂𝘁𝗶𝗼𝗻 𝗮𝗻𝗱/𝗼𝗿 𝘀𝗸𝗶𝗻 𝗰𝗮𝗿𝗲 𝗽𝗿𝗼𝗳𝗲𝘀𝘀𝗶𝗼𝗻𝗮𝗹 𝗳𝗿𝗼𝗺 𝗹𝗶𝗮𝗯𝗶𝗹𝗶𝘁𝘆 𝗮𝗻𝗱 𝗮𝘀𝘀𝘂𝗺𝗲 𝗳𝘂𝗹𝗹 𝗿𝗲𝘀𝗽𝗼𝗻𝘀𝗶𝗯𝗶𝗹𝗶𝘁𝘆 𝘁𝗵𝗲𝗿𝗲𝗼𝗳.
Signature
Date

MonthDayYear
Should be Empty:

Skin Concerns

Allergies

Aromas/ Accommodations

Skin History

Health Conditions

Daily Medications

Daily Skin Care (1x, 2x, Weekly, Varies)

Lifestyle

Future Appointments/ Contact

Service Consent: