Client Consultation & Intake Form

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What are your main goals for your skin?

If you selected "Other", please explain below.

Describe your current skincare routine (products used, frequency, etc.)

Do you have any of the following health conditions?

If you selected "Other", please explain below.

Are you currently taking any medications? If yes, please list them.

Do you have any allergies (including to skincare products or ingredients)?

Appointment

Is there anything else you would like us to know about your skin or health?

By signing this form, you acknowledge and agree to receive skincare services provided by Jamylette Santiago, who is currently enrolled in an esthetics program and is not yet licensed.

You understand that there is a possibility of skin sensitivity or adverse reactions to products used during or after the service. By consenting to receive these services, you voluntarily assume any associated risks and agree that Jamylette Santiago shall not be held liable for any reactions or outcomes resulting from the service.

You further acknowledge that these services are provided free of charge for educational and practice purposes only.

Signature