New Client Intake Form for Aesthetic Services

New Client Intake Form for Aesthetic Services

Please fill out your general information, pertinent medical and/or medication history, and consent details to help us service you safely.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about us?
Date of last hair removal in the treatment area(s):

MonthDayYear
Date
What hair removal type(s) have you used in the treated area(s)?

Other
Which service(s) are you considering today?
Please list all allergies and/or sensitivities.
Please list all medical conditions (e.g., diabetes, epilepsy, skin disorders).
Please list all medication use (topical, oral, etc.).
Waxing Contraindications: Please indicate if you have/are taking any of the following.

Other
Lamination Contraindications: Please indicate if you have any of the following.

Other
Tinting Contraindications: Please indicate if you have/do any of the following.

Other
Which of the following pertain to your lifestyle:
Please list all current skincare, body care, and prescription products relevant to your treatment area(s).
Are you currently pregnant or breastfeeding?
We may ask to take photos, video, or audio during your visit for educational or promotional purposes. We will always ask for your verbal consent before anything is captured or used. Do you agree to this?
Post-Wax Care Acknowledgment: I understand that waxing is a controlled injury to the skin and hair follicles. For a minimum of 24–48 hours following my waxing service, I agree to avoid activities that may expose the treated area to excessive heat, moisture, friction, bacteria, UV exposure, or irritation. This includes, but is not limited to: sexual activity involving the treated area, swimming or submerging the area in water, saunas and steam rooms, sun exposure or tanning, strenuous exercise causing excessive perspiration, tight-fitting clothing, and the use of exfoliating, fragranced, or otherwise potentially irritating products. I understand that following these aftercare instructions is essential to reduce the risk of irritation, infection, folliculitis, ingrown hairs, skin sensitivity, and post-inflammatory hyperpigmentation. I acknowledge that my esthetician cannot guarantee results and is not responsible for adverse reactions resulting from failure to follow recommended aftercare instructions (initial below to agree).
Should be Empty: