Reeset Esthetics New Client Intake Form

Reeset Esthetics New Client Intake Form

Facial
Client's Name

First NameLast Name
Gender

MaleFemale
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
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 VeinsOther
Are you taking any medication? If so please list below.
Self skin assessment

NormalOilyDryAcneOther
How does your skin heal from a break out or cut?

FastPigmentsScarsSlowOther
How do you take care of your skin at home? List your skin care products.
Do you have any allergies? Please list all (including food allergies)
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 currently on accutane or have you been in the past 6 months?

YesNo
Have you had any filler or Botox in the past 2 weeks?

YesNo
In the last 5 days have you or plan to,

Had/Had any waxing or depilatories on your face?Had/Have any exposure to the sun?
In the last 48 hours have you used Retin-A, Retinol?

YesNo
Terms & Conditions
I understand that my data will be strictly confidential. Reeset Esthetics 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, Reeset Esthetics will not be liable.

I release Reeset Esthetics and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Reeset Esthetics New Client Intake Form

Terms & Conditions