Client SkinTake Questionnaire

Client Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
- Which of the following best describes you? (This question helps determine your customized treatment plan)
- Please Take a Moment to Answer the Following Questions:
- What are your current skin concerns and/or goals?
- If Other please explain here:
- Have you noticed any recent changes or symptoms?
- If your are currently experiencing any breakouts, dark spots, and/or pigment changes, please share when they began, where they occur, and any known triggers.
- Please describe your daily skin care regimen and name of products you are currently using below.
- Please Take a Moment to Answer the Following Questions:
- Do you have any known allergies or sensitivities?
- If yes, please list any allergies, reactions, to skin care ingredients, medications, latex, fragrances, or other relevant substances.
- Are you currently experiencing irritation or sensitivity around your eyes?
- If yes, please briefly describe your symptoms.
- Do you have any diagnosed skin conditions or medical conditions that may affect your treatment?
- If yes or unsure: please describe including any ongoing medical care.
- Are you currently using any prescription medications, topical treatments, or products that may affect your skin?
- If yes or unsure: please list the names, including acne medications, retinoids, and medicated creams.
- Have you had any there any recent cosmetic treatments, procedures, or health changes that may affect your facial?
- If yes or unsure: Please explain. Examples include recent injections, peels, laser treatments, surgery, pregnancy, or breastfeeding.
- Are there any other concerns or medical issues not listed that you may currently have that the esthetician should know about?
- Are any of the following currently applicable to you? (Select all that apply)
- How do you typically maintain your facial hair?
- Do you experience any concerns related to shaving?
- Which of the following lifestyle factors apply to you?
- How Often Do You Exercise/Active?
- How would you describe your daily water intake?
- How often do you wear sunscreen?
- May we take before/after photos to privately document your skin's progress?
- May Noire use your photos/video for educational, or promotional purposes, including social media?
- Would you like to join our Noire Inner Collective on Instagram for skincare + wellness insights?
- If Yes, What is Your Instagram Username?
- Stay Connected to our Monthly Newsletter!
- I understand that the services provided are for cosmetic/wellness purposes. Skincare treatments may involve temporary redness, dryness, irritation, sensitivity, breakouts, or other adverse reactions, even when appropriate precautions are taken.
  
  I agree to provide accurate and complete information regarding my health history, allergies, medications, and skincare products. I understand that withholding relevant information or not following recommneded aftercare instructions may increase the risk of complications.
  
  I understand that individual results vary, and no results are guaranteed. Consistent skincare practices, appropriate home care, and recommended follow-up treatments may help support my skin goals.
  
  I acknowledge that Noire Naturels Aesthetics personnel Ariel Sibley (Licensed Esthetician) is not a DERMATOLOGIST or PHYSICIAN. If chronic or medical skin concerns arise, she reserves the right to modify, defer (postpone), or decline a treatment when necessary for client safety and may recommend evaluation by an appropriate healthcare professional.
- I have read and understood the information above, had the opportunity to ask questions, and voluntarily consent to the proposed facial treatment.
- I understand that my personal and health information will be handled confidentially and used for client assessment, treatment planning, recordkeeping, and related services.
  
  Noire Naturels Aesthetics takes reasonable measures to safeguard client information. Records may be processed through authorized service providets and disclosed when required or permitted by law, consistent with applicable privacy requirements.
  
  My information and treatment photos will not be used for public marketing without my separate consent.
- Please Check the Box Below to Acknowledge And Approve.
- Client Signature
- Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: