New Client Intake Form

New Client Intake Form

The following information helps me understand your skin, lifestyle, and goals so your treatment can be fully customized to you. Your answers allow me to provide the safest, most effective care while supporting long-term skin health. Please answer all questions to the best of your abilities. All information will remain private & confidential. I look forward to meeting you soon!
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
[email protected]
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name & Mobile
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals?
What do you love about your skin
Please select your primary skin concerns:*

Acne / BreakoutsWrinkles / Fine LinesTexture / ScarringPigmentation / Sun DamageDry / FlakyRedness / RosaceaSensitivityExcess OilOther
Please list any additional concerns you would like your esthetician to know:
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?

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

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

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?*

Yes, currently usingYes, but not within the last 14 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product(s) if applicable:
Have you received any of these facial services in the last 30 days?*

Waxing / Sugaring / ThreadingElectrolysis / LaserBotox / Dermal Fillers / Facial InjectablesNone
Date

MonthDayYear
Date
Your Health
Medical History*

AnemiaAuto-Immune DisordersBlood Clot DisorderBruise EasilyCancerDiabetesEczemaEpilepsy / Seizure DisorderFibromyalgiaGut ImbalanceHeart DiseaseHepatitis A / B / CHerpes Simplex (Cold Sores)High Blood PressureHIV / AIDSHormonal ImbalanceLupusMetal ImplantsMigraines / HeadachesNeurological DisordersPacemakerPsoriasisRosaceaSkin DieaseStaph Infection / MRSAThyroid ConditionOtherNoneSurgery
If you checked yes to any of these, please provide further information.
Please list any allergies (eg: aspirin, latex, nuts, essential oils, etc.):*
Have you ever had a reaction from a product or treatment on your face? If yes, please explain.*
Are you currently taking any prescription / over the counter medications? If yes, list below or put “none.”*
Do you smoke or vape?*

YesNo
Do you wear contacts?*

YesNo
Do you frequent a tanning bed / booth?*

YesNoSometimes
Do you see a dermatologist?*

YesNo
Female Clients
Do you use birth control?

YesNoNo, but within the last 12 months
If Yes, which kind?
Are you pregnant, nursing, or trying to conceive?

PregnantNursingTrying to conceiveNone
Any menopause issues?

YesNoN/A
Please list any additional information you would like to make your esthetician aware of:*
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 in your client file.*

YesYes, but block out my eyesNo
Policies
Terms & Conditions
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, this clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature*

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Date Signed*

MonthDayYear
Date
Should be Empty:

New Client Intake Form

Your Skin

Your Health

Female Clients

Policies

Terms & Conditions