Client Intake Form

Client Intake Form
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Were you referred by anyone?
Please take a moment to answer the following questions
Please Check All That Apply

AcneArthritisDiabetesEczemaFever BlistersHeart ConditionsHepatitisHigh Blood PressureLow Blood PressureLupusSinus InfectionSurgeryPsoriasisRashesSeborrheaShinglesSkin CancerHyper/Hypo ThyroidWartsOther
Are you presently taking any medications?

YesNo
Have you had skin cancer?

YesNo
Are you pregnant?

YesNo
Are you taking oral contraceptives?

YesNo
Do you have any allergies to cosmetics, food or drug?

YesNo
What skin care products do you currently use?

Cleanser Oil/BalmFacial CleanserBar SoapFacial Scrub/ExfoliantsChemical ExfoliatorTonerAntioxidant SerumHydrating SerumEye CreamSpot TreatmentMoisturizerSunscreenFace OilOther
Have you used Retin-A, Renova, Accutane, Adapalene, Differen, BHAs, Glycolic/Lactic/Mandelic Acids, Retinol, or other Vitamin Products?

Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Have you received Botox, Juvederm, Restylane, or Collagen injections within the last 6 months?

YesNo
Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last 30 daysYes, within the last 3 monthsYes, within the last yearNo
Have you been under the care of a dermatologist within the past year?

YesNo
If yes, explain:
Have you had any type of facial hair removal within the last 30 days?

WaxingThreadingDermaplaningShavingElectrolysis/LaserDepilatory CreamOther
What concerns do you have regarding your skin?

Acne/BreakoutsBlackhead/WhiteheadsClogged PoresDrynessHyperpigmentation/Sun DamageExcessive Oil/ShineRednessRosaceaScarringFine Lines/WrinklesSensitivityOther
I agree to the following statements:
- I acknowledge that I have read and completed this questionnaire truthfully. I understand that this document supersedes any previous verbal or written disclosures.
- I understand that withholding information or providing inaccurate information may lead to adverse reactions, including skin irritation, from the treatments received. If I experience any pain or discomfort during the session, I will inform the esthetician immediately so that the products and/or techniques can be adjusted to my comfort level.
- I further understand that a facial treatment should not be considered a substitute for a medical examination, diagnosis, or treatment.
- I recognize that estheticians are not qualified to diagnose, prescribe, or treat any physical or mental illnesses, and that nothing discussed during the session should be interpreted as such.
- I agree to keep the esthetician informed of any changes in my medical profile during the session, and I understand that the esthetician will not be liable if I fail to do so.
- I acknowledge that any illicit or sexually suggestive remarks or advances made by me will result in the immediate termination of the session.
Additionally, I understand that;
- The services provided are not a substitute for medical care. Any information given by the esthetician is for educational purposes only and should not be considered as diagnostic or prescriptive advice in the future.
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Client Intake Form

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