Start your Skin Journey with SAE SKIN

Start your Skin Journey with SAE SKIN

New Client Intake Form
Client's Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
How did you hear about SAE SKIN?*

InstagramTikTokFacebook GroupGoogle SearchReferralOther
If you were referred to SAE SKIN, who introduced you to us?
What would you like to prioritize during your visit as we begin your skin journey?*

Guidance on your home care routineSupport for current skin concerns (acne, sensitivity, pigmentation, etc.)Time to relax and resetCreating a personalized plan for long-term skin health
Do you want me to explain what I’m using during your facial?*

Yes, I love learning as we goNo, I’d rather relax and hear details laterEither way works for me!
Your Skin & Lifestyle

Help me get a holistic picture of your skin, habits, and goals so we can create the most personalized plan for you.
How would you describe your skin type?*

DryOilyCombination (both dry & oily)SensitiveUnsure
Which of the following do you notice in your skin?*

Breakouts / AcneRednessClogged poresFlakiness / Dry patchesExcess oil / ShineSensitivity / Easily irritatedDehydration / TightnessUneven tone / PigmentationTexture / BumpsMelasma / Sun DamageWrinkles / Fine linesReacts to certain products
What’s currently part of your daily skincare routine? (Check all that apply)*

Cleanser (gel, cream, oil, etc.)Bar soapToner or essenceSerums (vitamin C, hyaluronic acid, etc.)MoisturizerSunscreenEye or lip careI’m not using anything right now
Please upload a photo of your current AM/PM skincare products! This helps me get a clear view of what you're using so I can better support your skin goals.*

A quick photo of your products is perfect — shelf, flat lay, or however you store them is totally fine. Just make sure I can read the labels!
Cancelof
How does your skin typically heal after a breakout or injury?*

Heals quickly, no marks left behindLeaves red or brown pigmentation (post-acne marks)Scars easily (indentations, texture changes)Heals slowly or takes a long time to fadeUnsure
How does your skin usually respond to sun exposure?*

Always burns, never tansUsually burns, tans with difficultySometimes burns, gradually tansRarely burns, tans easilyNever burns, always tans
How would you describe your current stress levels?*

Low – I feel balanced most daysModerate – I’m managing but could use more supportHigh – I feel overwhelmed or stressed oftenIt changes day to dayI'd rather not say
How many hours of sleep do you typically get per night?*

Less than 5 hours6–7 hours7–8 hoursMore than 8 hours
How much water do you drink daily?*

Less than 20 oz20-40 oz a day40-64 oz a dayMore than 64 oz
What professional skin treatments have you had before? (Facials, peels, microneedling, injections, laser, etc.)
When was your most recent treatment?*

Within the last 4 weeks1–3 months ago3–6 months ago6+ months agoNot sure / never had one
Have you had any of the following in the last 2 weeks? (Check all that apply)*

Facial waxingMicroneedlingLaser treatmentInjections (Botox, filler, etc.)Chemical PeelNone of the above
Health History

Knowing your health history helps me ensure your treatments are safe and fully customized to your needs. All information is kept confidential.
Are you currently pregnant, breastfeeding, or planning to become pregnant?*

NoYes – pregnantYes – breastfeedingYes – planning/trying
Do you have a history of any of the following? (Check all that apply)*

Epilepsy or seizuresThyroid disorderAutoimmune disorderHeart condition or pacemakerHigh or low blood pressureDiabetesCancer (current or past)Cold sores / fever blistersSkin conditions (eczema, psoriasis, rosacea)Hormonal imbalance (including PCOS, menopause)Keloid scarringActive acne medication (e.g., Accutane)None of the above
Are you taking any medications (oral or topical) that may affect your skin’s sensitivity (ex: antibiotics, steroids, acne medications)?*

YesNo
If yes, please list them below:
Are you currently using or have you recently used any of the following: Retin-A/tretinoin, adapalene, Accutane, Differin, or over-the-counter retinol?*

Yes, currently usingYes, but stopped within the last 14 daysYes, but stopped within the last 30 daysNo
If yes, please list the product(s) and how often you're using them:
Important Notes Before Your Appointment:
- Please discontinue the use of retinol, Differin, or Retin-A at least 7-10 days prior to your facial.
- Avoid facial scrubs or exfoliants 1 week before your appointment.
- If you are currently on Accutane or have used it recently, please consult with your doctor before booking.
Are you currently taking any blood-thinning medications (e.g., aspirin, warfarin, Plavix)?*

YesNo
Do you have any of the following?*

Contact lensesPacemakerMetal implantsFacial piercingsNone of the above
Do you have any known allergies or sensitivities to the following?*

Aspirin (salicylates)Tree nuts (including oils)LatexDairyIodineShellfish or marine-derived ingredientsFragrance or essential oilsOther (please specify)None
Other allergies or sensitives. If there is anything else you would like me to know - please list here!
*SAE SKIN WILL NOT BE HELD RESPONSIBLE FOR ANY ALLERGIC REACTIONS DUE TO UNDISCLOSED ALLERGIES*
Photo & Video Consent

(Please read and sign)
Do you give consent for videos and/or photos to be taken for treatment documentation and progress tracking?*

YesYes, with eyes coveredNo
Do you give consent for your videos and/or photos to be used for social media or marketing purposes?*

YesYes, with eyes coveredNo
By submitting this form, I understand and agree that:
- Photos and/or videos taken during my treatments may be used for internal documentation and progress tracking.
- If I have given consent above, these materials may also be used for marketing or promotional purposes, including but not limited to social media, website, and print.
- I may withdraw or update this consent at any time by providing written notice.
- My identity will be protected to the best of SAE SKIN’s ability, especially if I select the “eyes covered” option.
Client Signature*

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SAE SKIN Client Consent & Studio Policy Agreement

These guidelines help protect the space I hold for you and other clients. Please read carefully.
I understand that my facial treatment at SAE SKIN may include one or more of the following:
- Double cleansing, enzyme or acid exfoliation, extractions, customized peels, LED light therapy, plasma infusion, facial massage, nano-infusion, and tailored mask applications.
This form provides consent for both foundational and advanced treatments. By submitting this form, you acknowledge and agree to the following:

✨TREATMENT UNDERSTANDING
- These services are professional, non-medical treatments intended to support skin health and appearance.
- Results are not guaranteed and may vary depending on individual skin condition, age, lifestyle, medications, and consistency with home care.
- I understand that photos may be taken for internal documentation and progress tracking. (Marketing photo/video consent is requested separately.)
⚠️REACTIONS + RISKS
- I may experience temporary effects such as redness, sensitivity, tightness, dryness, flaking, purging, or breakouts.
- I understand that visible peeling may or may not occur, even when exfoliating or resurfacing treatments are performed.
- In rare cases, irritation, inflammation, pigment changes, or allergic reactions may occur.
🧬MEDICAL DISCLOSURE
- I have disclosed all health conditions, medications (oral and topical), allergies (e.g., aspirin, latex, shellfish, fragrance, nuts), and recent or upcoming cosmetic procedures (waxing, injectables, laser, microneedling, etc.).
- I confirm that I am not currently on Accutane or similar medications, and have paused topical retinoids or exfoliants within the advised timeframe.
- I am not pregnant or breastfeeding, or I have disclosed that I am.
- I understand it is my responsibility to inform SAE SKIN of any health or medication changes prior to future appointments.
🌞PRE & POST CARE AGREEMENT
- I will follow all instructions before and after my treatment, including:
  - Avoiding sun exposure, sweating, or heat for at least 24–72 hours
  - Wearing SPF 30+ daily
  - Not picking or peeling the skin
  - Delaying any other facial or resurfacing services unless cleared.
- I understand that failure to follow post-care may affect results or increase sensitivity.
🛑LIMITATION OF SCOPE
- I understand these treatments are cosmetic in nature and do not substitute for medical advice, diagnosis, or care. My esthetician is not a medical provider.
💼STUDIO POLICIES & CANCELLATION TERMS
- A nonrefundable deposit is required to book all appointments. This deposit will go toward your service total the day of your visit.
- If you cancel or reschedule with more than 24 hours’ notice, your deposit will be automatically refunded or applied to a future appointment.
- If you cancel with less than 24 hours’ notice, arrive more than 15 minutes late, or do not show up to your appointment, the deposit will be forfeited.
- If this happens more than once, you may be required to prepay in full for future services.
- All sales are final. Services are nonrefundable once rendered.
- SAE SKIN services are cosmetic and for educational purposes only. They are not a substitute for medical care.
- All personal and medical information shared is confidential.
📜CONSENT + RELEASE
- I understand the nature of the treatments offered and give my voluntary, informed consent to proceed.
- I release SAE SKIN and its provider from any liability related to known or unknown skin reactions that may occur, provided proper protocols were followed.
- This consent remains valid for future services unless revoked or updated in writing.
By checking this box, I confirm that I have read and understood the information above and voluntarily agree to the terms of this consent.
Client Signature*

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