New Client Intake Form

New Client Intake Form

Please fill in this form before your appointment:
How did you find me?

GoogleInstagramInfluencerReferral
In the case of referral: Who referred you?
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary reason for visit:*

Congestion - BlackheadsBreakouts - AcnePremature AgingTexturePigmentationScarringWrinklesSensitivityI just want to learn how to take care of my skin
How would you describe your skin?

OilyDryCombinationSensitiveMatureCongestedOther
Have you had the following procedures in 2-4 weeks?*

BotoxFillersMicrodermabrasionChemical PeelingLaserUltra Violet ExposureVaccinationsNone of the above
Are you currently under a doctor’s care?*

YesNo
Do you have a skin care routine?*

YesNo
List your current skincare routine. You may also upload a picture:
Upload your skincare routine:

Cancelof
Has your routine been working for your current skin concerns?*

YesNo
Do you suffer any of the following diseases?

EczemaDermatitisCancerDiabetesKidney DisorderEpilepsyHormone ImbalanceMetal PlatesClaustrophobiaAnxietyDepressionAllergiesAsthmaHeart ProblemsHIVHepatitisStrokeBlood DisordersThyroid DisordersHigh Blood PressureLow Blood PressureSkin DisordersVision ProblemsNone of the above
List any allergies to products, foods or medications (if applicable):
Are you currently taking any of these medications?*

AspirinAnti-coagulants (blood thinners)Hormones/contraceptivesAppetite suppressant (diet pills)Thyroid medicationInsulinSedativesTranquilizersCortisone/SteroidAccutaneRetin-A or RetinoidsHerbal SupplementsNone of the aboveOther
List any medications, herbal supplements and vitamins that you are currently taking:
When was your last exposure to the sun?

2 days ago4 days agoA week ago2 weeks ago1 month agoLonger than a month ago
Circle your skin type when exposed to the sun for 1-2 hours without sunscreen.

Always burns never tansAlways tansSometimes burns, sometimes tansAlways burns, sometimes tansBlack spotsOther
Do you wear sunscreen on a daily basis?

YesNo
Are you pregnant, lactating, or planning a pregnancy soon?

YesNo
Anything you would like to add?
TERMS AND CONDITIONS

I understand, have read and completed this medical history form truthfully.

I agree that the withholding information or providing misinformation may result in contradication or irritation to the service being received.

I declare that the above information I have given concerning my health is correct.

Consent: I understand and voluntarily accept the risks associated with all facial services. I agree that this waiver is in effect for all services, and will not expire unless specifically requested by either party.

By signing this form, I agree to the above terms, authorizing the Esthetician to retain my personal information on my private client account, and release the Esthetician and its employees from any liability or claims.

We will not treat clients with: questionable medical conditions, open wounds or sores, infections recent dental work, healing incisions, etc.

I understand that the treatments I receive are not substitution for medical treatment.
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