Heavenly Glow Aesthetics

Heavenly Glow Aesthetics
New Client Intake Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Gender

FemaleMale
Step 1: Skin Behavior & Condition
1. How does your skin feel at the end of the day?

Tight or DryOily & ShinyCombinationBalanced
2. How often do you experience breakouts?

RarelyFrequentlyOccasionallyNever
3. Do you notice redness, irritation, or sensitivity?

OftenOccasionallyRarelyNever
4. What happens when you don’t moisturize your skin?

Feels tight, flaky, or uncomfortableFeels normal, no major changesBecomes oily in certain areasBecomes greasy or shiny
5. How visible are your pores?

Barely visibleEnlarged, especially in the T-zoneNormal size but noticeable in some areasVery visible
Step 2: Skin Care Routine
6. How often do you cleanse your skin?

Once a dayTwice a dayA few times a weekRarely
7. Do you use any exfoliating products? (scrubs, acids, peels, etc.)

Yes, regularly (1-3 times a week)OccasionallyNo, never
8. What is your current go-to skincare product?

CleanserMoisturizerSunscreenSerumNone
Step 3: Sun Exposure & Protection
9. How often do you wear sunscreen?

Every dayOnly when outsideRarelyNever
10. How sensitive is your skin to the sun?

Burns easily, rarely tansSometimes burns, sometimes tansTans easily, rarely burnsNever burns, always tans
Step 4: Your Skin Type and Goals

Based on your answers, we’ll determine your skin type:
11. What are your top skincare goals? (Choose all that apply)

Hydration and moistureClear acne or blemishesBrighten dark spots or hyperpigmentationReduce fine lines and wrinklesImprove overall skin textureMinimize pores and control oilCalm sensitivity or redness
12. Are there any products you currently avoid due to allergies or past reactions?

YesNO
Please List:
13. Any other concerns or notes about your skin you’d like to share?
Consent
I confirm that the information provided is accurate and can be used to create a customized skincare regimen for me.
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Heavenly Glow Aesthetics

New Client Intake Form