Client Intake Form

Client Intake Form
Thank you for taking the time to complete this form.
I know it’s a bit long, but every question helps me get to know your skin, lifestyle, and goals so I can create the best personalized routine and recommendations for you.

All of the information you share is completely confidential and used solely to provide you with safe, effective, and customized skincare guidance.

I truly appreciate you taking the time to fill this out — it allows me to give you the most accurate advice and best results possible.
Client's Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
Health + Skin Background
Do you have any of the following conditions? If yes, please select them:

Other
Are you taking any medications that is related to cosmetic or skin improvement?
Do you have any known allergies (especially to skincare ingredients, medications, or foods)?
Are you currently under the care of a dermatologist or physician for skin concerns?
Do you take any medications (including birth control, Accutane, or supplements)?
Have you had any recent cosmetic treatments (chemical peel, laser, microneedling, Botox, etc.)?
Describe your skin type is it (Oily, Dry, Combination, Normal, Sensitive)?
Do you experience:Acne or breakouts, Rosacea or redness, PigmentationFine lines or wrinkles, Sensitivity or irritation, DehydrationIf yes, how long have you been experiencing these concerns?
List your morning routine (cleanser, toner, moisturizer, SPF, etc.) with product name.
List your night routine (cleanser, toner, moisturizer, SPF, etc.)
Are you using any prescription products (like tretinoin, antibiotics, etc.)?
Have you had any reactions or sensitivities to skincare in the past?
Are you pregnant?
Are you trying or planning to be pregnant?
Are you taking any contraceptive pills?
Are you breastfeeding?
Have you undergo any surgeries?
Please explain any surgeries:
Lifestyle & Habits

Skin health is affected by your lifestyle.
Are you currently under any kind of diet?
Do you smoke or vape?
How much water do you drink daily?
Describe your typical diet (balanced, fast food, plant-based, high sugar, etc.)
How often do you drink alcohol?
Do you take any supplements or vitamins?
How often do you exercise? How do you take care of your skin after working out?
How would you rate your stress level? (Low / Moderate / High)
Skin Goals
What are your top 3 skin concerns or goals?
How soon are you hoping to see results?
How committed are you to following a consistent skincare routine?
Have you worked with an esthetician before?
Before & After Photo Upload

To help me evaluate your skin and track your progress, please upload clear before and after photos of your skin.
Photo Guidelines
Please follow these steps to ensure clear and accurate skin photos for your virtual consultation:

Preparation
Ensure your skin is clean and makeup-free — no tinted moisturizer or SPF.
Remove any jewelry or accessories that may cover your face or neck.

Lighting & Setting
Take your photos in natural daylight, near a window or bright, well-lit area.
Avoid shadows, artificial yellow lighting, or overhead lights that distort skin tone.
Use a plain white or neutral background if possible.

Camera Tips
Use your phone’s back camera for the best quality.
If possible, ask someone to help take the photos to ensure proper angles and clarity.

Required Angles
Please include three clear photos of your face from these angles:

Front view – looking straight ahead.
Left side profile.
Right side profile.
If you have specific skin concerns or problem areas, include close-up photos of those areas as well.

Confidentiality
These photos are kept strictly confidential and are used only for professional assessment and progress tracking, unless you provide written consent for them to be shared.
File Upload

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Before & After Photo Consent

As part of your skincare journey, I may request before-and-after photos to help track progress and showcase treatment results. These photos help evaluate improvements and, with your written consent, may also be used for professional education or marketing purposes (social media, website, or promotional materials). Your privacy is very important to me. No photos will ever be shared publicly without your explicit written permission.
Client Signature
Date Signed

MonthDayYear
Date
Terms & Conditions
I understand that my data will be strictly confidential. This clinic 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 this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
CONSENT & LIABILITY AGREEMENT
I acknowledge that the information I have provided is accurate to the best of my knowledge. I understand that Alexis (Skin Therapist) is a licensed esthetician providing virtual skincare consultations and personalized product recommendations. These consultations are educational and for skincare guidance only, not a substitute for medical diagnosis or treatment.

I understand that results vary depending on individual skin types, conditions, and lifestyle factors. I agree to follow recommendations at my own discretion and release Alexis from any liability related to adverse reactions, allergies, or results from the use of recommended products or advice provided.

By signing below, I give my consent for Alexis Mae to provide virtual skincare guidance and to use my intake information for professional reference only.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Client Intake Form

Health + Skin Background

Lifestyle & Habits

Skin Goals

Before & After Photo Upload

Before & After Photo Consent

Terms & Conditions

CONSENT & LIABILITY AGREEMENT