Skin Binge Client Intake Form

Customer Details:

Full Name*

First NameLast Name

Date of Birth*

Date

Phone Number*

E-mail*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Parent or Guardian if Client is Under 18 Years Old

First NameLast Name

How did you hear about us?*

Please Specify

Do you use any of these:

	When	How Long	Last Taken/Used
Antibiotics
Accutane
Benzoyl Peroxide
Estrogen
Testosterone
Progesterone
Retina-A
Retinol
Tretinoin
Tazorac
Differin
Clindamyein
Quinine
Lithium
Thyroid
Azelex
Avita
Celocin-T
E-Myein-T
Compaxone
Corticosteroids
Androstenedione
Daniel
Isoniazid
Steroids
Marijuana
Cocaine/Speed
Other
Other
Other
None

Do you use birth control pills, shots, or IUD? If so, which kind?*

Are you pregnant, nursing, or trying to conceive?*

PregnantNursingTrying to conceiveNone

Please select Yes or No *

	Yes	No
Diabetes
Cancer
HIV/AIDS
Herpes Simplex (Cold Sores)
Eczema
Psoriasis
Staph Infection/MRSA
Thyroid Condition
Autoimmune Disorders
Neurological Disorders
Lupus
Anemia
Hemophilia
High Blood Pressure
Pacemaker
Gall Bladder Removal
Ovary(ies) Removed
Hysterectomy
Epilepsy or Seizures
Hormonal Imbalance
Gut Imbalances/Intolerances
Blood Clot Disorder
Heart Disease
Fibromyalgia
Migraines/Headaches
Hepatitis A/B/C
Bruise Easily
Skin Disease
Rosacea
Metal Implants

Any other medical conditions? If yes, list below or put "none."*

Please list any allergies*

Have you ever had a reaction from a product or treatment on your face? If yes, please list:*

Do you see a dermatologist?*

YesNo

Do you smoke or vape?*

YesNo

Do you frequent a tanning bed/booth or tan in the sun?*

YesNoSometimes

Do you wear contacts?*

YesNo

Please list your Primary Care Physician (name + contact number) or NONE*

Please list your current at-home skincare routine/products:

	Please list product names or NA:
Cleanser
Toner
Serums
Moisturizer
Sunscreen
Masks
Other
Other
Other

Please select your primary skin concerns:

	Please select:
Acne
Aging
Texture
Pigmentation
Pore Size
Scarring
Sunburn
Elasticity
Other

Please list any additional skin concerns and your long term goals:*

Do you prefer a "silent appointment"?*

YesNoNo preference

Do you consent to photos/videos being taken/shared on social channels? Please Note: treatment photos are still stored on your client file.*

YesNoYes, but block out eyes

Skin Binge Esthetics Policies:

Cancellation/No-Show/Reschedule Policies:

Skin Binge sends out multiple appointment reminders: first when your appointment is made, 48 hours before your appointment, 24 hours before your appointment, and 1 hour before your appointment via email and text. You are given multiple chances to cancel/reschedule ahead of your appointment to avoid the different fees.

Skin Binge asks that you please reschedule or cancel at least 48 hours in advance or you will be charged a $50 cancellation/rescheduling fee. Any cancellations/reschedulings prior to 48 hours in advance will not require the $50 fee. Any no-shows or cancellations/reschedules with 12 hours or less notice will be charged 50% of the service fee.

Failure to pay cancellation or rescheduling fees will result in blockage from booking future appointments until paid. After 2 no-shows or same day cancellations, you will not be able to book further appointments with Skin Binge.

Reschedules with less than 24 hours notice will be required to adhere to the above mentioned policies for cancellations.

Grace Period Policy:

Skin Binge gives a 10-minute grace period to arrive to your appointment. Clients that are late to their appointments may run the risk of their treatments/appointments being shortened but still charged the full service fee OR may be required to pay 100% of the service fee and reschedule.

Under-age Client Policy:

All clients under the age of 18 are required to have a parent or legal guardian present at all of their appointments.

Guests Policy:

For liability reasons, no other guests may be present at your appointment unless you are an under-age client attending with your parent or legal guardian.

Compliance to Guidance:

Due to the nature of the business, Skin Binge frequently gives clients instructions for treatment pre-care and post-care, home care products, lifestyle factors, etc., that affects client skin progress and health. By signing below, you understanding that you must follow any and all instructions given to you by your Skin Binge provider and understand that failure to do so may result in lack of results or compromised skin health due to failure to adhere to policier and guidance on your part and do not hold Skin Binge liable.

Credit Card On-File Policy:

An active credit card is required to be on file for each client in case of failure to adhere to any of the above mentioned cancellation, no-show, or rescheduling policies. You will on be charged with the card on file in case of failure of adherence to these policies or unless the card on file is your chosen payment preference for treatments, products, etc. If your card on file is declined, you will be asked to pay via a different method or may risk being blocked from future treatments and purchases from Skin Binge and you will also be asked to update the card on file. You will be asked to provide your card info below and authorize Skin Binge to add your payment card to your file.

We appreciate your understanding and compliance!

I understand and agree to the policies

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.

I understand and agree to the terms and conditions.

Client Signature*

Date Signed*

Date

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