New Client Intake Form

Date*

MonthDayYear

What's your name?

First NameLast Name

How did you hear about Club Bay? If you were referred, please let us know who referred you below.

Phone Number

Please enter a valid phone number.

E-mail*

example@example.com

What's your birthday?

Date

Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry

Occupation

Allergies

What are your skin goals and objectives? *

What are your skin care challenges?*

What does your at home skincare routine consist of?

Have you ever had a facial or skin treatment before?

YesNo

If Yes, what and when?

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?

Please specify which product or type, if you answered 'Yes, currently using' to above

Have you received any of these services in the last 30 days?

If yes, please specify

Have you experienced any of these health conditions in the past or present?*

If you checked yes to any of these please provide further information. If not mark N/A*

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo

If yes, please specify what and date last used

Do you smoke?

YesNo

Do you consume caffeine?

YesNo

Do you wear contact lenses?

YesNo

Are you taking contraceptive medication?

YesNo

If yes, please specify

Are you undergoing any hormone replacement therapy?

YesNo

If yes, please specify

Post Treatment Care Instructions:

Avoid Sun Exposure: Protect your skin from direct sunlight for at least 48 hours post-treatment. Use a broad-spectrum sunscreen with SPF 30 or higher if sun exposure cannot be avoided.
Keep Skin Hydrated: Drink plenty of water to keep your skin hydrated from the inside out. Apply a gentle, non-comedogenic moisturizer to the treated area as needed to prevent dryness and promote healing.
Avoid Harsh Products: Refrain from using harsh skincare products, exfoliants, or abrasive scrubs on the treated area for at least one week post-treatment. Stick to gentle, non-irritating skincare products to avoid irritation or inflammation.
Avoid Touching or Picking: Resist the urge to touch or pick at the treated area to prevent infection or scarring. Let your skin heal naturally without interference.
Follow Specific Instructions: If your skincare provider provided specific post-treatment instructions or recommendations, follow them carefully to optimize results and minimize any potential complications.
Stay Cool: Avoid activities that may cause excessive sweating or heat exposure, such as strenuous exercise, saunas, or hot tubs, for at least 48 hours post-treatment. Heat can exacerbate inflammation and irritation.
Monitor for Side Effects: Keep an eye out for any unusual or adverse reactions, such as excessive redness, swelling, itching, or blistering. If you experience any concerning symptoms, contact your skincare provider immediately.
Follow-Up Appointment: Schedule a follow-up appointment with your skincare provider as recommended to assess treatment outcomes, address any concerns, and determine if additional sessions are needed.

I have read the post care instructions and agree to adhere to them*

yes

I understand the reservation and cancellation policies at Club Bay, if I fail to give 24 hour notice for appointment cancellations or rescheduling that I will be automatically charged 50% of the service, and 100% if I fail to notify 2 hours prior to services or if I no-show.

I understand and agree to the Cancellation Policy

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof. I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I release Club Bay LLC and hold harmless against any claims, expenses, damages, and liabilities.

I understand and agree to Terms and Conditions

Signature*

New Client Intake Form

Your Skin

Your Health

Cancellation Policy

Terms and Conditions