Client Intake Form

Client Intake Form

FLORAMER SKIN STUDIO
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Email Address
example@example.com
Do you have any of the following conditions? If yes, please select them:

CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsMetal Tooth FillingsOther
Do you have any of the following allergies? If yes, please select them:

CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther
Skin condition

NormalOilyDryAcneOther
How does your skin heal?

FastPigmentsScarsSlowOther
How do you take care of your skin at home?
What would you like to achieve from your treatment today?
Do you consume alcohol?

YesNo
Are you pregnant?

YesNo
Are you trying or planning to be pregnant?

YesNo
Are you taking any contraceptive pills?

YesNo
Are you breastfeeding?

YesNo
Do you consume caffeinated drinks?

YesNo
Are you wearing any contact lenses?

YesNo
Are you currently under any kind of diet?

YesNo
Have you undergo any surgeries?

YesNo
Have you received any fillers or botox in the last 4 weeks?

YesNo
What beauty or cosmetic products you're currently using?
Are you taking any medications that is related to cosmetic or skin improvement? (Accutane, Retin-A, Any Topical or Oral RX)
Terms & Conditions
I understand that my data will be strictly confidential. Floramer Skin Studio does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release Floramer Skin Studio and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature

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Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Terms & Conditions