Client intake form

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Email

Occupation

Emergency Contact Name

Emergency Contact Number

Yes, subscribe me to your newsletter.

How did you hear about us?

Medical History

Are you currently taking any medications?

If yes, please explain:

Have you had any facial or dermatology services in the past 30 days?

If yes, please explain:

Do you have any allergies?

If yes, please explain:

Skin Care History

What type of skin do you have?

Conditions you are currently experiencing today (please select all that apply):

Important Information

Have you been under the care of a dermatologist within the past year?

If yes, please explain:

Have you used Retin-A, Renova, AHAs or Retinal/Vitamin A products in the last three months?

If yes, please explain:

Have you received Botox, Restylane, or Collagen injections in the last 6 months?

If yes, please explain:

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the

technician of any changes in the above information. I agree that I do not have any condition(s)

that would make the requested treatment unsuitable. I will inform the technician of any

discomfort I may experience at any time during my treatment to allow them to adjust

accordingly. I agree to waive all liability toward my technician and the salon for any injury or

damages incurred due to any misrepresentation of my health.

Name Printed

Date

Month

Day

Year

Signature

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