New Client Intake Form
Name
*
First Name
Last Name
Phone Number:
*
E-mail
*
example@example.com
How did you hear about Wildflower Skincare?
*
If Referral, please list name
Have you ever had a facial or skin treatment before?
*
Yes
No
What are your skin concerns?
*
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Dryness
Oiliness
Texture
Dullness
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
Other
What Skin Care Products do you currently use?
*
Cleanser / Face Wash
Bar Soap
Face Scrub
AHAs
BHA (Salicylic Acid)
Retinol/Retin A
Hydroquinone
Mask
Toner
Serums
Vitamin C
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Other
Have you had any of the following treatments?
*
Chemical peel
Microdermabrasion
Laser/IPL
Microneedling
Chemotherapy
None
Other
If yes, please specify the treatment date:
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
*
Yes
No
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
*
Yes
No
Have you ever been prescribed Accutane? if yes, for how long and when was your last date used?
*
Your Health
Are you currently on any medications? If yes, please specify:
*
Have you experienced any of these health conditions in the past or present?
*
Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Other
None
If other, please list
Do you?
*
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
Not Applicable
Do you have known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Are you a smoker?
*
Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Any additional information you would to inform your esthetician:
Cancellation and Late Arrival Policies
Cancellation: If you need to reschedule or cancel your appointment, we respectfully request 24 hour notice. Cancellations or rescheduling without 24-hour notice or no-shows will result in a 50% charge of the total service amount to your credit card.
*
Yes, I understand and agree to the terms and conditions of the cancellation policy
Late Arrival: If you are late for your appointment, we will try our best to accommodate. However, please keep in mind that your service time may be shortened in order for us to be on time for the next client. You will still be responsible for the full amount of your services including the services which we did not have enough time for.
*
Yes, I have read and agree to the terms and conditions of the late arrival policy.
I have completed this form to the best of my knowledge and agree to inform the esthetician of any changes with the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I agree to waive all liabilities toward my esthetician for any injuries or damages incurred due to any misrepresentation of my health history.
*
Yes
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: