Vain Skin Studio

Vain Skin Studio

Client Intake Form
Client's Name

First NameLast Name
Gender
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:

Other
Are you currently taking any medications?
If so, what are they?
Do you have any allergies? If so, please list below.
How would you describe your skin?
How does your skin heal?

Other
What is your AM & PM skincare routine?
What are you looking to get out of today's treatment?
What are your short term goals for your skin?
What are your long term goals for your skin?
What prompted you to book today's treatment?
Are you trying or planning to be pregnant? *this is important so we are using pregnancy safe products & home care*
Are you taking any contraceptive pills, have an IUD, Depo shot, etc?
Have you done any of the following treatments within the past year?
Are you taking any medications that is related to cosmetic or skin improvement?
Who can we thank for referring you?
Are you comfortable with your photos being posted on Vain Skin Studio's social media and website?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic 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, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
I understand that cancellations within 48 hours of my scheduled services are subject to a 50% cancellation fee and if I no call no show I will be subject to a 100% service charge.
Date Signed

MonthDayYear
Date
Should be Empty:

Vain Skin Studio

Terms & Conditions