Client Intake Form

1
Welcome!

I’m Christine, and I’m so excited to help you on your skincare journey. My goal is to provide you with a facial experience that’s tailored to your skin's unique needs. We’ll work together to nurture your skin’s health while focusing on holistic wellness to help you glow from within.

Please fill out this form to allow me to create a personalized facial experience just for you!
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
4
Email
example@example.com
5
Were you referred by another client? If yes, who referred you?
6
Have you had a facial before?
No
Other
7
Do you know your skin type?
Oily
Dry
Combination
Acne prone
Sensitive
Other
8
What is your primary skin goals?
Clear skin
Hydration
Brightening
Anti-aging
Reducing Redness
Monthly maintenance
Other
9
What are your main skin concerns?* This field is required.
Acne
Hyperpigmentation
Wrinkles
Dryness
Rosacea
Eczema
Other
10
Do you prefer a quiet, relaxing facial with minimal conversation, or would you like me to converse with you and educate you on the products and techniques I’m using during your treatment?
I prefer a silent, relaxing facial.
I enjoy some conversation and learning about product and techniques being used.
11
Have you ever had an allergic reaction to a skincare product or ingredient? If yes, what was it?* This field is required.
No
Other
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Do you have any preferences for the type of products used (organic, vegan, etc.)?
Organic
Vegan
Other
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Are you comfortable with extractions?
Yes
Please skip
Other
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Are you currently using any strong skincare actives (retinol, AHAs, BHAs, Vitamin C, etc.)?
Retinol
BHS's
AHA's
Vitamin C
Peptides
Other
15
Are you currently experiencing any skin irritation or sensitivity?* This field is required.
No
Other
16
Are you pregnant or taking birth control?* This field is required.
Taking birth control
No
Other
17
Do you have any pace makers, metal implants, or heart conditions?* This field is required.
No
Other
18
Do you have any skin conditions or concerns that I should be aware of?
No
Other
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Pre-Facial Care Instructions

To ensure the best results, please follow these guidelines before your appointment:

Avoid Exfoliation: Stop using exfoliating products (scrubs, acids) for at least 3 days before your facial.
Pause Retinoids & Actives: Discontinue retinoids, AHAs, BHAs, and other strong actives 5-7 days before your appointment.
Limit Sun Exposure: Stay out of the sun and avoid tanning beds for at least 48 hours prior to your facial.
Stay Hydrated: Drink plenty of water to keep your skin hydrated.
Avoid Hair Removal: Do not wax or use depilatory creams on your face for at least 48 hours before your treatment.
Skip Other Treatments: Avoid Botox, fillers, or other cosmetic procedures for 1-2 weeks before your facial.
Arrive Makeup-Free: Please come with clean, bare skin—no makeup, sunscreen, or heavy skincare products.
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Appointment Policy Reminder

If you need to cancel or reschedule, please let me know at least 24 hours in advance to avoid a 50% cancellation fee of your booked service.

Also — for everyone's comfort and safety, no guests are allowed during appointments. Thank you so much for understanding!
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I’d love to showcase your beautiful results on my page! Do I have your permission to share photos/videos taken during or after your appointment for social media and marketing?
Yes, I'm okay with it, share away!
No thanks, I'd like to keep things private.
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Acknowledgment

I confirm that the information provided in this questionnaire is accurate and complete. I understand that failure to provide full information may cause adverse reactions or skin irritation.

I have reviewed the pre-facial care instructions and understand that not following them may affect the outcome of my treatment. I have disclosed all necessary medical history, allergies, and skincare routine details.

By signing, I agree to these terms.
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Client Full Name blanks *
Date: blank
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Signature
Should be Empty: