Skin Treatment Client Intake Form

Skin Treatment Client Intake Form

Update form as needed.
Client's Name

First NameLast Name
Gender

FemaleMale
Today's Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Occupation
Who referred you or how did you hear about us?
Do you have any of the following conditions? If yes, please select them:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Skin Condition

NormalDryOilyAcneOther
How do you take care of your skin at home?
What are your skincare goals?
Are you under the care of a dermatologist?

YesNo
Skin Sensitivities/Allergies?
Are you using any of the following?

Glycolic AcidLactic AcidHydroxy AcidVitamin AVitamin CNone
Do you use any of the following?

AccutaneRetin ARenovaAdapaleneNone
Have you had any of the following in the last two weeks?

Chemical PeelMicrodermabrasionBotoxFillersLaser/IPLNone
Have you had botox or fillers in the last two weeks?

YesNo
Do you wear contact lenses?

YesNo
Are you allergic to Aspirin?

YesNo
Are you currently pregnant?

YesNo
Do you have metal implants?

YesNo
Do you have a pace maker?

YesNo
Do you have body piercings?

YesNo
Have you been diagnosed with cancer in the last six months?

YesNo
In the last week, have you gotten waxed?

YesNo
Have you been tanning in last 24 hours?

YesNo
Have you undergone any surgeries in the last 3 months?

YesNo
What skincare products are you currently using?
Are you taking any medications or supplements?
Terms & Conditions
I understand that my data will be strictly confidential. Skincare Sanctuary does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, Skincare Sanctuary will not be liable.

I release Skincare Sanctuary and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Skin Treatment Client Intake Form

Terms & Conditions