Esthetics Intake Form
Please provide your personal information below. Thank you!
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Minutes
AM
PM
AM/PM Option
Full Name
*
Please type first and last name.
Phone
*
Email Address
*
example@example.com
Have you ever had a Facial?
Yes
No
Conditions you are currently experiencing today (Please select all that apply):
Headache
Inflammation
Muscle Cramps
Anxiety
Fatigue
Insomnia
Stress
Skin Cancer
Hormonal Imbalance
High Blood Pressure
Diabetes
Auto-Immune Disorder
Epilepsy/Seizures
Cold Sores
What type of skin do you have?
Normal
Oily
Dry
Combination
Have you been under the care of a dermatologist within the past year?
*
YES
NO
If yes, please explain...
What areas of concern do you have regarding your skin?
Breakouts/Acne
Blackheads/Whiteheads
Uneven Skin Tone
Sun Damage
Excessive Oil/Shine
Wrinkles/Fine Lines
Dull/Dry Skin
Rosacea
Broken Capillaries
Redness
Dehydrated
Melasma
Other
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Sunscreen
Drugs
Iodine
Pollen
AHAs(Glycolic/ Lactic Acid)
Fragrance
Shellfish
Latex
BHA(Salycilic Acid)
Vitamin C
Retinol, Retinoids
Aspirin
Shea/Coconut Butter
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
*
YES
NO
If yes, please specify...
Give me an idea of what you typically use on your skin daily?
Soap
Cleanser
Toner
Serum
Mask
Exfoliant
Eye Cream
Moisturizer
Retinol
SPF
Are you Pregnant or Breastfeeding?
Yes
No
Have you had any facial waxing in the past 7 days?
Yes
No
Client Signature
*
Submit
Submit
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