Client Intake Form

Aesthetic Services
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CLIENT INTAKE FORM
CLIENT NAME
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency contact name and number
Phone #
Format: (000) 000-0000.
Email
example@example.com
How did you hear about us
Do you have any of the following conditions? If yes, please select them:
Any other condition
Please explain
Do you have any allergies? including but not limited to food, product, environmental
List any medications you take regularly including vitamins, herbal supplements, aspirin
explain
Surgeries (including cosmetic procedures)
Explain
Are you pregnant/ breastfeeding
Have you received Neurotoxin/ Dermal Filler in the past month? If yes , when?
Have you ever had a facial before? If yes please explain what type of facial and when
What are your main skin concerns?
What would you like to achieve from your treatment today
Please select any products you currently use
What is your skin type? (Oily,dry, combination, blemished, acne)
How many minutes of sun exposure do you get in a day?
Is your skin sensitive or sensitized?
How often do you wear makeup
I have completed this form, truthfully and to the best of my knowledge. I agree to inform the aesthetician of any changes in the above information. I agree that I do not have any condition that would make the requested treatment unsuitable. I agreed to waive all liabilities toward the Aesthetician or Beauty Room by Rae for any injury or damages due to any misinterpretation of my health.
Printed Name
Signature
Should be Empty:

Aesthetic Services

CLIENT INTAKE FORM