New Client Intake Form

New Client Intake Form

Welcome! I am excited to work with you and learn more about you and your skin! Once I have your responses, I will provide you with a zoom link for our scheduled time. During your session we will discuss your skincare goals and you will be provided a personalized skin care routine. Please allow up to 24 hours for a response.
Client's Name*

First NameLast Name
Preferred Name*
Pronouns*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is the best way to contact you?*

EmailText MessageCall
How did you hear about Beyond the Face Spa & Wellness (@thedigitalesthie)?
How would you describe your skin?

DryNeutral/NormalCombinationOilyNot sure
After you wash your face it feels:

Tight or DryNo particular sensationSlight sheenOilyNone of the above
How does your skin feel a few hours after using moisturizer?

DryOilyDry in some area and oily in othersI don't use moisturizerNone of the above
What are your skin goals? (check all that apply)

Prevent wrinklesBetter, healthier skinTo address my skin concerns
What are your face and/or body skin concerns (check all that apply)

SensitivityRednessFine lines or wrinklesLoss of firmness or elasticityHyperpigmentationAcneDrynessRosaceaDull SkinEczema (on face)Stretch MarksEczema (on body including scalp)Psoriasis (on body including scalp)Dry/Cracked LipsCold Sores/Fever BlistersScarring (acne, surgical etc.)Other
How old are you?*

20 or below21-2627-3334-3940-4647-5455-6465 or older
Do you wear make-up?
Do you have a current skincare routine?
If you answered "Yes or Somewhat" to the question above, what does it consist of? (Check all that apply)

CleanserTonerSerumSunscreen or moisturizer with SPFMoisturizer without SPF or face oilEye CreamRetinol or Retin-AExfoliantOther
Are you looking to replace your current skincare routine?
Are you allergic to any skincare ingredients (If Yes, please list them below)blanks
Would you like to partner with Pomifera?

When you partner with us you will not only get paid for sharing our products with those you know, but you will also be compensated if you gather people who want to partner and share the brand right along with you.

Order a business box ($99) and receive a variety of the Pomifera Brand Products, a replicated website that your referrals can order directly from, as well as instant access to your Owner's Suite that puts running a small business right at your fingertips. No monthly or yearly fees, ever!

Whether you choose to partner as a part time hobbyist or you have big goals for building substantial incomes, we are proud to have you as part of the Pomifera family.
Are you interested in the Pomifera Opportunity

Yes, sign me up!I would like more informationI want to try the products firstNot interested
Questions or comments?