New Client Intake Form

How did you find me?

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.Format: (000) 000-0000.

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary reason for visit:

How would you describe your skin?

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

Are you currently under a doctor’s care?

Do you have a skin care routine?

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

Upload your skincare routine:

Has your routine been working for your current skin concerns?

Do you suffer any of the following diseases?

List any allergies to products, foods or medications (if applicable):

Are you currently taking any of these medications?

List any medications, herbal supplements and vitamins that you are currently taking:

When was your last exposure to the sun?

Circle your skin type when exposed to the sun for 1-2 hours without sunscreen.

Do you wear sunscreen on a daily basis?

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

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.

Signature

Today's Date

Date