New Client Intake Form

  • New Client Intake Form

  • Please complete this intake form truthfully and thoroughly, providing enough detail to help us prioritize your safety and provide the best care possible.

  • Date
     / /

  • Contact Information

  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Skin History

  • How would you describe your skin?*
  • If you selected oily: When does your skin start to feel oily?
  • Do you tend to get dark spots easily after acne or skin inflammation?*
  • Do you tend to burn easily in the sun?*
  • Does your skin tend to become red after experiencing any of the following: extreme weather, stress, eating spicy foods, drinking alcohol, heated beverages, indoor heat, humidity, hot baths, sun, and/or wind.*
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  • Are you currently under the care of an esthetician or dermatologist?*
  • Have you received any of the following procedures in the last 90 days?*
  • Have you used any of the following topical/oral dermatological medications?*

  • Medical History

  • Please check if you are allergic to:*
  • Have you ever had any of the following conditions?*
  • Do you have any other medical concerns that have not been covered in this form? Please list below.*
  • Are you currently undergoing any hormone therapies or taking any infertility drugs?*
  • Are you currently pregnant or breastfeeding?*
  • Are you currently taking birth control pills or have an IUD?*
  • Are you currently experiencing perimenopause or menopause?*

  • Lifestyle Considerations

  • Do you wear contact lenses or eyeglasses?*
  • Are you currently under a lot of stress?
  • Are you in the habit of using tanning beds?*
  • Have you had excessive sun exposure in the last few days?*
  • Will you be having excessive sun exposure in the near future (such as a planned vacation)?*

  • Preferences

  • Are you sensitive to smells/fragrances?*
  • Would you like a silent appointment? (limit speaking/conversation to only what's necessary for your treatment)?

  • Failure to Disclose

    It is your responsibility to provide Cherish Beauty Aesthetics with all your relevant medical details and health history prior to each treatment. We will not be liable for any damage that occurs because of your failure to disclose such details.
  • I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.*

  • Terms & Conditions

  • Should be Empty: