Have an account?

Client Intake Form

Today's Date

First name

Last name

Email

Phone

Birthday

Month

Day

Year

When was your last facial?

0-3 Months Ago

3-6 Months Ago

6-12 Months Ago

Never Had a Facial Before

Were there any adverse reactions during or after your service? If so, explain.

Please list any current skin conditions (such as acne, rosacea, eczema, dermatitis, psoriasis, open wounds, etc). If not applicable, please indicate using N/A.

Please list any known allergies (medications, skincare ingredients, latex, nuts, etc.). If not applicable, please indicate using N/A.

Are there any medical conditions I should be aware of prior to your appointment (diabetes, epilepsy, heart conditions, pregnancy, etc.)? If not applicable, please indicate using N/A.

Are you currently under a doctor's care or taking any prescribed medications (Accutane, antibiotics, steroids, blood thinners, etc.)? If not applicable, please indicate using N/A

Have you recently undergone surgery or a medical procedure involving your face or neck?

Yes

No

Do you have any implanted medical devices or conditions that may affect your ability to receive electrical modalities such as microcurrent or high-frequency treatments?

Yes

No

Have you taken isotretinoin (Accutane) within the past 12 months?

Yes

No

Are you primarily seeking relaxation, corrective skincare, preventative maintenance, or a combination?

Relaxation

Corrective Skincare

Preventative Maintenance

Combination of all

Are there any skin concerns you would like to discuss with your esthetician in detail at your appointment? (Please explain)

How did you hear about us?

CONSENT & ACKNOWLEDGEMENT

By checking this box, I acknowledge that I understand that the facial services I receive are not a substitute for medical care. I confirm that the information provided above is accurate and complete. I agree to inform my esthetician of any changes to my health or skincare routine.

By checking this box, I acknowledge that I understand facial treatments are designed to improve the appearance of the skin, however, results vary depending on my skin type, lifestyle, and consistency with at-home care. I acknowledge that possible side effects may include temporary redness, dryness, flaking, breakouts, sensitivity or irritation. I have disclosed all relevant medical history and skincare use and I accept responsibility for following the recommended aftercare protocol.

Do you consent to before and/or after photos/videos being taken and potentially used for marketing purposes such as social media, website or my portfolio?

Yes, I give my consent.

No, I do not give my consent.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.