Client Intake Form

Date*

MonthDayYear

Name*

First NameLast Name

Date of Birth

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

E-mail*

example@example.com

How did you hear about me?

If Referral, please list name

If Other, please let me know

What are your skin care goals? *

What are your skin care challenges? (Check all that apply)*

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?

YesNo

If Yes, when?

How sensitive of skin do you have?

Very SensitiveSensitiveNormal

From the following list, please check all that apply.

I have a family history of skin cancer.I have been diagnosed with skin cancer.I am currently being treated for cancer.

How many of the following treatments/services have you experienced before?

How much sun exposure do you get per day?

Above AverageAverageBelow Average

Are you pregnant or currently lactating?

YesNoRecently had a baby and am breastfeeding

Any known allergies?*

If Other, please specify

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo

If yes, please specify what and date last used

What do you expect from this treatment?

Emergency Contact Information

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

I, blanks am the client/legal guardian and agree to treatment for skin and health related conditions to be treated by Alter’d Image Inc. I consent treatment for blank (child's name). I understand that payment for treatment will be collected in full at time of appointment. I understand that failure to cancel or reschedule appointment within 24 hours of appointment time, if I am unable to make the original appointment time will result in a $50 cancellation fee, and for this reason I agree that the card on file will be charged in such event.

Explanation of Services: I understand that I will be receiving skincare services, which may include but are not limited to facials, chemical peels, waxing, and other related treatments.
Treatment Risks: I acknowledge that there may be potential risks and side effects associated with skincare services. These risks may include skin irritation, redness, swelling, or other adverse reactions. Explanation of these risks have been explained to me.
Product Usage: I consent to the use of skincare products and tools during the treatment. I have disclosed any known allergies or sensitivities to medications as well as accurate records or topical medications and medications taken orally.
Medical Conditions: I have provided accurate information regarding my medical history, including any allergies, medications, medical conditions, or recent skincare treatments.
Expectations: I understand that the results of skincare services may vary and depend on various factors, including my skin type, condition, adherence to aftercare/home-care and frequency of treatments.
Aftercare: I agree to follow the aftercare instructions provided, to ensure the best possible results and minimize the risk of complications.
Consent for Photography: I grant permission for Alter'd Image Inc. to take before and after photos for documentation and professional use.
Cancellation and Rescheduling: I understand the cancellation and rescheduling policy of Alter'd Image Inc. and will adhere to it.
Payment: I agree to pay for the skincare services as per the pricing and payment terms explained to me.
Emergency Contact: I have provided accurate emergency contact information in case of any unexpected events during the treatment.

I have had the opportunity to ask questions and seek clarification on any concerns I may have had. I voluntarily consent to the skincare services provided by and understand the potential risks associated with these services.

Client's Signature*

Client Intake Form

Your Skin

Health Conditions & Allergies