Skyn By Em Client Intake Form

Client Intake Form

Skyn By Em
Full Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address
City
State
Zip
Emergency Contact
Name
Phone Number
Format: (000) 000-0000.
Relationship
Medical History
(Please check all that apply and provide explanations where necessary)

Other, please list.
Have you had a cold sore in the last 6 months?

If so, please list when.
Are you currently under the care of a physician?

Yes, list reason.
Are you currently taking any medications (topical or oral)?

Yes, please list.
Do you have any allergies (especially to skincare ingredients, food, latex, etc?

Yes, please list.
How would you describe your skin?
Do you have any of the following skin concerns?

Other, please list.
Do you currently use any of the following?

Other, please list.
Please list your current skincare routine/products:
Cleanser
Toner
Serums
Moisturizer
SPF
Other
Lifestyle & Habits
Do you smoke or vape?
How often do you drink alcohol?
How often are you exposed to the sun or tanning beds?
How is your water intake?
Are you currently pregnant or breastfeeding?
What are your main skin concerns?
I certify that the information provided is accurate and complete. I understand that this information is used to determine appropriate skincare treatments and will be kept confidential. I agree to inform my esthetician of any changes to my health or skincare routine in the future.
Signature
Date

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Date
Should be Empty:

Client Intake Form