• Client Intake Form

    Share your details, service preferences, and any relevant skin or health information.
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • What are your main skin concerns?*
  • How would you describe your skin type?*
  • Have you received any cosmetic treatments in the past 6 months? (e.g., chemical peels, laser treatments, injectables)
  • Do you have any known medical conditions or diagnoses?*
  • Are you currently under the care of a physician or healthcare provider?*
  • Have you had any surgeries or medical procedures within the past 12 months?*
  • Are you currently pregnant, trying to become pregnant, or breastfeeding?*
  • Do you have any history of fainting, seizures, or severe dizziness?*
  • Do you have any history of blood-clotting or bleeding disorders?*
  • Do you have diabetes?*
  • Do you have an autoimmune disorder?*
  • Do you have a history of keloid or abnormal scarring?*
  • Do you have any heart or cardiovascular conditions?*
  • Do you have any immune-system disorders?*
  • Are you currently taking any prescription medications?*
  • Are you taking any over-the-counter medications or supplements?*
  • Have you taken isotretinoin (Accutane) within the past 6–12 months?*
  • Are you currently using prescription-strength skincare products?*
  • Are you using topical or oral antibiotics?*
  • Are you using retinoids, tretinoin, or retinol?*
  • Are you taking blood thinners or medications that may increase bleeding or bruising?*
  • Have you recently taken antibiotics or steroids?*
  • Do you have any known allergies?*
  • Do you have allergies to skincare or cosmetic ingredients?*
  • Do you have a latex allergy?*
  • Have you ever experienced an allergic reaction to a skincare, cosmetic, or aesthetic treatment?*
  • Have you ever experienced anaphylaxis?*
  • Do you have any known sensitivities to fragrances, adhesives, or topical anesthetics?*
  • Do you currently have any active skin infections, open wounds, sores, or lesions?*
  • Do you currently have cold sores or a history of herpes simplex?*
  • Do you have eczema, psoriasis, rosacea, or dermatitis?*
  • Do you have active acne, cysts, or inflamed breakouts?*
  • Do you have a history of hyperpigmentation or hypopigmentation?*
  • Have you recently experienced a sunburn?*
  • Have you had significant sun exposure or used a tanning bed recently?*
  • Do you have a history of abnormal wound healing?*
  • Have you had a chemical peel within the last 2–4 weeks?*
  • Have you had microneedling within the last 4–6 weeks?*
  • Have you had laser or IPL treatment recently?*
  • Have you had waxing or hair removal in the treatment area recently?*
  • Have you had Botox, fillers, or other injectables recently?*
  • Have you had any cosmetic surgery recently?*
  • Have you experienced complications from an aesthetic treatment in the past?*

  • Photo Consent

  • Before & After Photo Consent

  • I understand that photographs may be taken before, during, and/or after my treatment to document my skin’s condition and treatment progress. These photographs may be used as part of my client treatment records and for professional documentation.
  • Before & After Photo Consent*

  • Marketing & Social Media Consent — Optional

  • Do you consent to have your photographs used for marketing purposes?
  • I understand that my name and other identifying information will not be publicly shared without my additional written permission. I may withdraw my marketing consent at any time for future use by contacting Mimi Beauty.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • I give Mimi Beauty permission to use my treatment photographs for marketing purposes, including social media, website, advertising, and promotional materials.
  • Should be Empty: