Client Intake Form
Your privacy is our priority. The information you provide helps us understand your skincare goals, assess the best treatments for your skin, and minimize any potential reactions. Rest assured, your details will be used solely to tailor your skincare experience and ensure your safety.
Full Name
*
First
Last
E-mail
*
We will never SPAM or sell email addresses to third parties.
Phone Number:
*
ex. 555-555-5555
Date of Birth:
*
ex. 11/11/2011
What is the best way to contact you?
Phone call
Email
Text
All
Any known allergies
*
Yes
No
If yes, please list allergies:
Are you currently under the care of a medical professional for any health-related issues
*
Yes
No
If yes, please elaborate:
Do you have any of the following health conditions or concerns ?
*
Pacemaker/other electronic implant
Claustrophobia
Autoimmune Disorder
Thyroid Disorder
Heart Disease
Stroke
Blood Clots
Asthma
Epilepsy
Electrophobia
Metal implant
High Blood Pressure
Diabetes
None
Other
Do you take blood thinners or medications that affect skin sensitivity?
*
Yes
No
If yes, please elaborate.
List all oral vitamins/herbs/supplements you take:
Do you currently use any of the following?
Retin-A
Renova
Adapalene
Differin
Glycolic Acid
AHA
Retinol
Accutane
Tazorac
RoAccutane
Scrubs or Peels
At home laser
I understand that I must discontinue use of ALL of the above 7 days prior to treatment. Accutane or Roaccutane must be discontinued at least 6 months prior to treatment.
*
Yes, I will discontinue.
Are you pregnant?
Yes
No
Are you currently nursing?
Yes
No
Are you taking oral birth control?
Yes
No
Do you have a Mirena IUD, Copper IUD or other implanted birth control?
Yes
No
Do you wear contact lenses?
Yes
No
Are you comfortable with the use of essential oils during your treatment?
Yes
No
If yes, what are your essential oil preferences?
What skin conditions would you like to improve?
Acne
Oily Skin
Dry Skin
Large Pores
Melasma
Redness
Brown Spots
Sun Damage
Milia
Sagging Skin
Rosacea
Lines & Wrinkles
Healthy Aging
Scarring
Age Management
Keratosis Pilaris
Hyperpigmentation
Any additional concerns?
What cosmetic injectables have you received, if any? And approximately when?
What skincare products are you currently using in the morning?
What skincare products are you currently using in the evening?
Please use this space for any additional notes.
I acknowledge that I have read and completed this questionnaire truthfully and to the best of my knowledge. I understand that this form constitutes full disclosure of my health and skincare history. I am aware that withholding information or providing inaccurate details may increase the risk of adverse effects to my health and safety. It is my responsibility to inform the esthetician of any changes to my medical or health conditions and to update this information as needed.
*
I understand and consent to the above statements.
Date
*
-
Month
-
Day
Year
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Signature
*
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