Intake + Consent Form
For clients under 18, a parent or legal guardian must provide the required information and consent.
Welcome to Allisonbskin!
Thank you for trusting me with your skin! Please complete this form prior to your appointment so that I can be fully prepared for your visit. I am so excited to see you!
Client Name
First Name
Last Name
Date of Birth
Email
example@example.com
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client Type:
Virtual
In Person
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Client Health History
Please click YES or NO if applicable.
Are you pregnant or trying to become pregnant?
YES
NO
Are you currently breastfeeding?
YES
NO
Allergies (food, ingredients, medications. latex, etc.):
YES
NO
If YES, please list:
Heart Condition:
YES
NO
Epilepsy/Seizures:
YES
NO
Recent Surgery (within 6 months):
YES
NO
Are you currently taking any medications?
YES
NO
If YES, please list:
Check if you are using any of the following:
Retinol / Retin-A / Tretinoin
Accutane (within the last 12 months)
Topical Antibiotics
Steroid Creams
Blood Thinners
Other
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Skin History + Goals
Please inform me of your skin history and concerns.
What are your main skin concerns?
Acne
Aging/Fine Lines
Hyperpimentation
Rosacea
Sensitivity
Dryness
Pore Size
Texture
Barrier Concerns
Other
How would you describe your skin type?
Oily
Dry
Normal
Combination
Sensitive
I'm not sure
Have you had a facial before?
YES
NO
Have you had any of the following in the last 2 weeks?
Chemical Peel
Dermaplaning
Microneedling
Laser Treatment
Waxing or Hair Removal
Botox/Neurotoxin/Filler
Other
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Current Skincare Routine
Please give me the details of your current skincare routine.
List your current skincare routine and products used.
Are you interested in personalized product recommendations?
Yes, I need a brand new routine!
I'm interested in a few new products!
No, I'd prefer to stick with my current products.
Is there anything else you would like me to know before your appointment?
Please share anything that would help personalize your treatment and make you feel more comfortable!
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Client Consent + Liability Release
Please Review and sign!
I have read and acknowledged the terms above.
I AGREE
I give permission for before and after photos/video content to be taken for treatment documentation and social media purposes.
YES
NO
Signature of Client (18+) or Parent/Legal Guardian of Minor:
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Should be Empty: