Client Intake

Basic Information

Start by telling us a little about yourself.

Full Name *

Date *

Date of Birth

Email *

Phone Number *

Street Address

City

State

ZIP

Occupation

How were you referred?

Skin Concerns and Goals

Tell us what you’d like to focus on so your treatment experience can be tailored to your skin.

What are your main skincare concerns?

Acne Pigmentation / age spots Lines around eyes Frown lines Lines around mouth Lip definition Skin laxity / sagging Broken capillaries Facial / body hair Sensitivity Dehydration Uneven texture Redness Other

Other concern

What are your main skincare goals?

Have you had a facial before?

Yes No

If yes, when was your last facial?

Do you perform facials or skincare treatments at home?

Yes No

If yes, how often?

Routine and Lifestyle

These details help create a more informed and personalized treatment approach.

How do you usually wash your face?

Soap Cleanser Other

If cleanser, what brand?

Do you use a moisturizer?

Yes No

What skincare products are you currently using?

Are you on a special diet?

Yes No

If yes, please describe

Do you drink water regularly?

Yes No

If yes, how much?

Coffee intake

Tea intake

Soda intake

Do you exercise?

Yes No

If yes, how often?

Have you had recent sun exposure or tanning?

Yes No

If yes, when?

Do you use self-tanner?

Yes No

Medical History and Contraindications

This information helps ensure your treatment is performed safely and tailored to your individual needs.

Are you currently under the care of a physician? *

Yes No

If yes, what for?

Current medications, supplements, or vitamins

Allergies

Please check any that apply

Accutane Antibiotics Birth control pills Hormones Aspirin / ibuprofen use Retin-A / Tretinoin Metrogel / MetroCream Glycolic acid reaction Sun reaction Antidepressants Diabetes Smoking Cold sores / herpes Bleeding disorders Autoimmune condition HIV Pregnancy Pacemaker Dental implants Breast implants Facial implants Migraines Glaucoma Cancer Arthritis Hepatitis Thyroid imbalance Seizure disorder Active infection Radiation in last 3 months Melasma Vitiligo Keloid scarring Tattoos / permanent makeup / microblading

Do you have any medication allergies?

Yes No

If yes, please describe

Do you have any food allergies?

Yes No

If yes, please describe

Specific allergies

Aspirin Latex Lidocaine Hydrocortisone Hydroquinone

Have you previously had any of the following?

Chemical peel Skin / laser treatment Botox Fillers Hair removal

If yes, please include when and results if known

Additional medical issues or information we should know

Consent and Confirmation

Please review and confirm the following before submitting your intake form.

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that results are not guaranteed and may vary. I understand that it is my responsibility to disclose relevant health information and updates. I agree to follow aftercare instructions provided for my treatment.

Printed Full Name *

Signature *

Consent Date *