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.
Have you seen a Dermatologist in the past year?
If Yes, please specify:
Please list any allergies or sensitivities
List any medications, supplements, vitamins etc that you take regularly?
Do you have any of the following conditions?
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.
What are your main skin concerns?

Other
If other please specify:
What do you consider your skin type?
What skin care products are you currently using on your face?

Other
Are you currently using any products that contain the following ingredients ?
Do you ever experience burning, itching or stinging sensations on your skin?
Have you ever had chemical peels, microdermabrasions or any resurfacing treatments?
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:
Should be Empty:

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