Client Intake Form Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Referred By Does your job require that you work outdoors? Yes No What would you like to achieve from your treatment? YOUR SKIN CARE Have you ever had a facial treatment before? Yes No If so, when? Have you ever had a body spa treatment before? Yes No Which of the following best describes your skin type? Creamy complexion - Always burns easily, never tans Light Complexion - Always burns, tans slightly Light/Matte Complexion - Burns moderately, tans gradually Matte Complexion - Seldom burns, always tans well Brown Complexion - Rarely burns, deep tan Black Complexion - Never burns, deeply pigmented Do you have any special skin problems or concerns pertaining to your face or body? Yes No Specify: Have you ever had chemical peels, laser or microdermabrasion? Yes No In the last month? Yes No Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? Yes No Please specify what was used and when: Have you used an acne medication? Yes No If yes, when & what drug? What skin care products are you currently using? (List brand where known) Have you recently used any self-tanning lotions, creams or treatments? Yes No If yes, specify: Have you used any of the following hair removal methods in the past six weeks? Shaving, Waxing, Electrolysis, Pluckin,g Tweezing, Stringing, Depilatories Yes No If yes, which method? Have you experienced Botox, Restylane, or collagen injections? Yes No Please specify: Please list all skin care products you are currently using (list brands if known) What areas of concern do you have regarding your skin: Breakouts/acne Blackheads/whiteheads Excessive oil/shine Rosacea Broken capillaries Redness/ruddiness Sun spot/liver spot/brown spot Uneven skin tone Sun damage Wrinkles/fine lines Dull/dry skin Flaky skin Dehydrated Other: What areas of concern do you have regarding your eyes: Dehydrated wrinkles Dark circles Puffiness Other: What SPF do you use on your face? How often do you use it? Have you had any recent tanning bed or sun exposure that changed the color of your skin? Yes No Please specify: HEALTH/LIFESTYLE Please list all allergies * Please list all medications * Please list all medical conditions * How many glasses of water do you drink per day? <1 glass 1-3 glasses 4-7 glasses 8+ glasses How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day? None 1-2 drinks 3-5 drinks 6+ drinks How many hours of sleep do you get per night? <3 hours 3-5 hours 6-8 hours 8-10 hours 10 + hours Do you exercise on a regular basis? Yes No Do you smoke, vape, or consume other tobacco products? Yes No What is your stress level? Please rate on a scale of 1-5. (1=low stress, 5=high stress) 5 4 3 2 1 FEMALE CLIENTS Are you taking oral contraceptives? Yes No Are you pregnant or tying to become pregnant? Yes No Are you experiencing any menopausal symptoms? Yes No Are you undergoing any hormone replacement thereapy treatments? Yes No MALE CLIENTS Do you experience irritation from shaving? Yes No Do you experience ingrown hairs as a result of hair removal? Yes No FUTURE APPOINTMENTS/CONTACT May I call/text you at the provided phone number to confirm future appointments? Yes No May I contact you via mail/email about future promotions and news? Yes No AGREEMENT Please read and agree to the statement below. * 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 the institution and/or the technician/esthetician/ skin care professional from liability and assume full responsibility thereof. I agree Electronic Signature * (First and Last Name) Today's Date MM DD YYYY Thank you! Your form had been submitted.
