Welcome, I’m so glad you’re here. In preparation for your next visit please help me get to know you and your skin.
FULL NAME:
EMAIL:
example@example.com
PHONE:
Format: (000) 000-0000.
DATE OF BIRTH:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
AGE:
BILLING ADDRESS
EMERGENCY CONTACT:
PHONE:
Format: (000) 000-0000.
SERVICE PREFERENCES
TODAY'S SERVICE REQUEST
AREAS OF CONCERN?
PRIMARY GOAL:
RELAXATION
SKIN CORRECTION
MAINTENANCE
ANTI-AGING
ACNE CARE
OTHER
PRESSURE FOR MASSAGE (if applicable)
LIGHT
MEDIUM
FIRM
MEDICAL & SKIN HISTORY
SKIN TYPE
NORMAL
DRY
OILY
COMBINATION
SENSITIVE
SKIN CONCERNS
ACNE
HYPERPIGMENTATION
WRINKLES
REDNESS
SCARRING
ALLERGIES
CURRENT MEDICATIONS
CONDITIONS
PREGNANT OR BREASTFEEDING?
YES
NO
PLEASE NOTE ON THE
PICTURE ANY AREAS OF
CONCERN
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FACIAL TREAMENT
CLIENT INTAKE FORM
Face Facts
esthetician
TREATMENT HISTORY
HAVE YOU HAD ESTHETIC SERVICES BEFORE?
YES
NO
ANY PREVIOUS ADVERSE REACTIONS?
DO YOU USE SUNSCREEN REGULARLY?
YES
NO
IF YES, WHICH:
FACIAL
WAXING
PEELS
MICRODERMABRASION
LASH/BROW SERVICES
Other
COSMETIC PROCEDURES:
BOTOX
FILLERS
LASER
Other
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
YOUR SKIN CARE ROUTINE
CLEANSER (FOAM/GEL/CREAM)
TONER / ESSENCE
SERUM (vitamin C, hyaluronic acid, etc.)
EYE CREAM
DAY CREAM / MOISTURIZER
NIGHT CREAM
FACIAL OILS
SUNSCREEN
EXFOLIANT (AHA/BHA/scrub)
MASK
SPOT TREATMENT (ACNE)
RETINOL / RETINOID
PRESCRIPTION CREAM (dermatologist)
OTHER:
Other
AFTERCARE ACKNOWLEDGMENT
I understand that certain treatments may cause temporary redness, peeling, or sensitivity.
I will follow recommended aftercare, including sunscreen use and avoiding harsh products for 24 - 48 hours.
I acknowledge results depend on my skin type, home care, and lifestyle.
(OPTIONAL)PHOTOGRAPHY CONSENT
I consent to before-and-after photos being taken for treatment records.
I consent to photos being used for educational or marketing purposes.
I confirm the information above is accurate and agree to services being provided under these conditions.
CUSTOMER:
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
CUSTOMER:
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FACIAL TREATMENT
CUSTOMER AGREEMENT
I acknowledge and agree to the following terms regarding professional skin care and esthetic services provided:
1. Scope of Services
Services will be carried out as discussed during consultation and recorded in the intake form. Treatments are customized based on skin type, concerns, and goals.
6. Scheduling & Cancellations
I understand that cancellations or rescheduling require at least 24 hours' notice. Late arrivals may shorten my service time, and missed appointments may be subject to a fee.
2. Health Disclosure
7. Confidentiality & Records
I confirm that I have disclosed all known health conditions, allergies, medications, and relevant medical history, including pregnancy or breastfeeding status. I understand failure to disclose information may increase the risk of adverse reactions.
All personal and medical information provided will remain confidential and used only for the purpose of treatment and record-keeping.
8. Termination of Services
3. Risks & Reactions
The esthetician reserves the right to refuse or stop treatment if conditions are unsafe, contraindicated, or if client conduct is inappropriate.
I acknowledge that certain treatments may cause temporary redness, sensitivity, breakouts, or peeling. Results vary depending on skin type, home care, and lifestyle.
4. Liability & Damages
The esthetician will take reasonable care during treatments. However, I understand the esthetician is not responsible for reactions caused by undisclosed conditions, failure to follow aftercare instructions, or pre-existing skin issues.
5. Aftercare Responsibility
I agree to follow the recommended aftercare provided, including sunscreen use, avoiding harsh products, and limiting sun exposure for 24-48 hours post-treatment.
BY SIGNING BELOW, I CONFIRM THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE TERMS ABOVE.
SIGNATURE
DATE
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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CLIENT INTAKE FORM
ADDITIONAL NOTES
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