Client Intake Form

Client Intake Form

Facial Services
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
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Please answer all questions thoroughly and truthfully.
YesNo
If Yes, please specify:
Please list any allergies or sensitivities *
List any medications, supplements, vitamins etc that you take regularly? *
AsthmaCold sores or Fever blistersEczemaCancerDiabetesDermatitisEpilepsyLupusHeart DiseaseHepatitisHormonal ImbalancesSunburnHIV/AIDSKeloids or hypertrophic scarsAutoimmune DisordersPsoriasisRosaceaWartsThyroid ConditionsNone
Rate your stress level on a scale of 1 to 5 *

1

2

3

4

5

1 is Low, 5 is High
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Please answer all questions throughly and to the best of your abilities.
Acne, breakoutsBlackheadsDry skinOily skinDehydrated skinDull SkinFine lines & WrinklesHyperpigmentation (Dark Spots)Keratosis PilarisIngrown hairsRosaceaEczemaScarringSkin rednessDark circles/ puffinessEnlarged poresPsoriasisOther
If other please specify:
Normal (no visible blemishes, fine pores, smooth texture)Oily (enlarged pores, excess oils)Combination (oily and dry patches, oily t-zone)Sensitive (redness, reactive to fragrances and temperature)Acne-prone skin (Cystic or nodules)Mature (dry, visible wrinkles/lines)Dry (tightness, roughness, flaking)Not sure
SoapCleanserTonerMoisturizerMasqueExfoliatorEye productsSunscreenSerumSpot treatmentFacial oilMakeup wipesNoneOther
Acne medicationAHA's (Glycolic Acid, Lactic Acid, Mandelic Acid etc.)Retinol/ Vitamin A derivative (Retin-A, Renova, Adapalene)BHA's (Salicylic Acid)Hydroxy AcidPrescribed topical creamsNone
YesNo
YesNo
If yes, when was it ?
Terms Of Service

I understand that withholding information or giving misinformation can contraindicate products used resulting in skin irritation. I understand that this is my responsibility to provide accurate information and if it is not provided Brazen Aesthetics is not liable.
Date of Birth *

MonthDayYear
Date
Please Sign: *
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Client Intake Form

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Terms Of Service

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