Esthetician Client Intake Consent Form

Esthetician Client Intake Consent Form

Skin and Health History
Client's Name*

First NameLast Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemaleNon Binary
Date of Birth*

MonthDayYear
Date
Referred by:*

FlyerAnother ClientInternetGoogleYelpMindbody AppSpafinderSmall street signsChiropractorPhysical TherapistLocal EventFacebookRadioNewspaperYellowpagesKingwood Business WomenLake Houston Chamber of CommerceOther
What is the reason for your visit today?*
Have you ever had a facial before?*
Have you ever been waxed before?
Are you under a physician's care for any current skin condition or other issue?
Have you had any piercings, tattoos, or permanent cosmetics? If yes, where on your person?
Please check the box next to the items that apply to you:*

CancerStressChronic HeadachesSkin CancerHypertensionHypotensionMetal ImplantsMetal Teeth FillingsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIVAIDSHerpesHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsWear ContactsWear DenturesConsume AlcoholSmokeExperience StressAcneAsthmaDrink CaffeineFrequent Cold SoresFollow regular exercise programActively dietingTake contraceptive pillsPregnantLactatingMenopause issuesNone of the aboveOther
Are you trying or planning to be pregnant?

YesNo
Any recent changes to or from your contraceptive treatment? If so, what and when?
Do you experience frequent blemishes? If yes, then how frequently?
Do you have any allergies? If yes, please list what you are allergic to:
Please list any medications, oral or topical:
Skin condition*

NormalOilyDryComboAcneOther
How does your skin heal?*

FastPigmentsScarsSlowOther
Do you form thick or raised scars from cuts or burns?*

YesNo
Are you currently under any kind of diet?

YesNo
Have you had any recent surgeries? If yes please explain:
Have you every used any of the following:

AzelexDifferinRenovaRetinaATarazacGlycolic AcidAHA AcidsAccutaneAdapalene Hydroxyl Acid
If you have used any of the above, when did you use them?
How do you take care of your skin at home?
How do you take care of your skin at work?
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.

I understand, and have read and completed this intake 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 know it is my responsibility to inform the esthetician/ skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this clinic and hold harmless against any claims, expenses, damages, and liabilities. I assume full responsibility thereof.
Client Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Esthetician Client Intake Consent Form

Terms & Conditions