SN Beauty Space Consultant form

New Client Skin Consult Intake Form
Date

MonthDayYear
Date
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Work Phone
Email Address*
example@example.com
Date of Birth

MonthDayYear
Date
Occupation
What is your hereditary background
Have you received any of the following procedures*

MicrodermabrasionLaser Hair RemovalEsthetic Laser Treatment (IPL, Fraxel, etc)Radio Frequency (RF) TreatmentsMicro-needlingFacial UltrasoundLED TreatmentFacial Waxing/Threading/Microblading Eyelash/Brow Tinting/Permanent MakeupNoneOther
What skincare products do you use on a daily basis?*

CleanserTonerAM MoisturizerPM MoisturizerSunscreenCorrective SerumFacial ScrubMaskNoneOther
Have you used any of the following topical/oral dermatological medications?*

Alpha Hydroxy Acids (glycolic, lactic, malic)Beta Hydroxy Acid (salicylic)Benzoyl PeroxideNot applicable
Are you currently taking birth control pills or have an IUD? (circle)*

YesNo
If yes please explain
Are you currently experiencing Perimenopause or Menopause?*

YesNo
If yes please explain
Are you currently pregnant or breastfeeding?*

YesNo
If yes please explain
Are you currently undergoing any hormone therapies or taking any infertility drugs?*

YesNo
If yes please explain
Current Medications (include over the counter)

Current Herbal Supplements and Vitamins
1
1
2
2
3
3
4
4
5
5
Are you having at least one bowel movement per day?*

YesNo
If yes please explain
Do you wear contact lenses or eyeglasses?*

YesNo
If yes please explain
Have you had excessive sun exposure in the last few days?*

YesNo
If yes please explain
Will you have excessive sun exposure on a vacation or in the near future?*

YesNo
If yes please explain
Are you in the habit of using tanning booths?*

YesNo
If yes please explain
Medical History
Have you ever had any of the following conditions?*

Cold Sores/ Fever Blisters Skin Disorder (i.e. Dermatitis)Hypertrophic Scarring (i.e. Keloids)Polycystic Ovarian Syndrome (PCOS)ConstipationSevere Headaches/Migraines Hepatitis Bleeding Disorder (i.e. Anemia)Thyroid DiseaseNot applicable
Do you have any other medical concerns not covered in this form?

YesNo
If yes please explain
How would you describe your skin?*
What are your current top 3 concerns with your skin and what improvements would you like to see?
1*
2*
3*
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Client Signature

Clear
Date

MonthDayYear
Date
ParentGuardian Signature If under age 18

Clear
Date

MonthDayYear
Date
EstheticianPractitioner Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

New Client Skin Consult Intake Form

Medical History