Client Consent & Intake
Full Name
First Name
Last Name
Date of Birth
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your gender?
Please Select
Male
Female
N/A
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Treatment history
Chemical peels
Laser treatments
Microneedling
Botox/fillers
Waxing
Cosmetic surgery
Facials
Other
Please list them.
General Health
Are you currently under a physician care?
Any recent surgeries?
Are you pregnant?
Any allergies?
Other
Please list them.
Do you have a history of:
Diabetes
High blood pressure
Heart conditions
Autoimmune disorders
Cancer
Epilepsy/seizures
Thyroid disorders
Hormonal imbalances
Keloid scarring
Skin condition
Other
Are you currently taking any medication?
Yes
No
Please list them.
Do you have any medication allergies?
Yes
No
Not Sure
Please list them.
Skin Concerns:
Acne
Hyperpigmentation
Aging/ fine lines
Dehydration
Senstivitiy
Scarring
Large pores
Texture
Sun damage
Other
Please list them.
Signature
Submit
Submit
Should be Empty: