THE REFINERY CLIENT INTAKE FORM

The Refinery Treatment Form

Client Consultation Form for Services with Brooke Bateman (LE, Reiki Master)
Client Information
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
ZIP Code
SKIN HISTORY
If there was something you could change or improve, what would it be?
Skin History
Other Issues not listed above:
LIFESTYLE
Please list caffeine sources
How many ounces of water daily?
How many cups of fruits/veggies daily?
What sources of protein do you ingest?
How often do you exercise?
Hormonal, Medical, and Treatment Screening
Are you currently taking birth control?
Birth control brand name
Are you currently pregnant? (Please know this information is kept confidential but is necessary for the safety of the unborn child.)
Are you currently menopausal or perimenopausal?
Do you use tanning beds?
Do you wear contact lenses or eyeglasses?
Have you ever had injections of Botox, Restylane, collagen, Jeuveau, etc.?
When was the last injection?
Medical Information
Other Medical Information (please explain)
Allergies to Specific Ingredients or Products
Recent Facial Surgeries or Treatments
Other Medical Concerns
Please List All Medications and Supplements You are Currently Taking
EMERGENCY CONTACT
Emergency Contact Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
SKIN CARE ROUTINE
Morning Skincare Routine (list names/brands)
These could be: Cleanser, toner, exfoliant, serum, eye product, day cream, night cream, spf
Evening Skincare Routine (list names/brands)
CONCENT AND SIGNATURE
I consent to before-and-after photographs being taken and used solely for marketing purposes. My name will not be disclosed, and identifying features will be obscured to ensure anonymity.
I understand that the facial treatment is not a substitute for medical treatment or advice. I have provided accurate information to the best of my knowledge. I consent to the facial treatment and agree to follow the technician's recommendations for aftercare and skincare. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

All services are strictly professional. Clients must respect the practitioner's boundaries. Any inappropriate behavior may result in ending the session and refusal of future services
Client Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Signature
Should be Empty:

The Refinery Treatment Form

Client Information

SKIN HISTORY

LIFESTYLE

Hormonal, Medical, and Treatment Screening

EMERGENCY CONTACT

SKIN CARE ROUTINE

CONCENT AND SIGNATURE