New Client Intake Form

Today's Date

Month

Day

Year

First name

Last name

Birth Date

Month

Day

Year

Phone

Email

Occupation

If referred, please list their name:

If other, please let us know:

Your Skin

Feel free to add more information if you would like:

Have you ever had a facial or skin treatment before?

Yes

No

If yes, when:

Please specify which product or type, if you answered 'Yes, currently using' to above.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Yes, within the last month

Yes, within the last 2-3 months

Yes, more than 3 months ago

No

Your Health

If you checked YES to any of these please provide further information. If not mark, NA

If other, please list:

If other, please specify:

Have you used or been prescribed any medications (topical or oral) for acne / acne control?

Yes

No

If yes, please specify what and date last used:

Are you a smoker?

Yes

No

Social

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)

Yes

No

Please rate your stress level:

Low

Medium

High

Female Clients

Are you taking birth control?

Yes

No

N/A

If yes, please specify:

Are you pregnant or trying to become pregnant?

Yes

No

Recently had a baby and am breastfeeding

N/A

Any menopause issues?

Yes

No

N/A

If yes, please specify:

Are you undergoing any hormone replacement therapy?

Yes

No

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Signature

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