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Skin Care Intake Form

Client Information Form- CONFIDENTIAL

WELCOME!  We would like to make your appointment as pleasant and comfortable as possible.  If at any time you have any questions regarding your session, please let us know.

All information is confidential. It will not be shared with or sold to any other companies or parties.

First Clients Name

First Name*

Middle Name

Last Name*

Phone*
First Clients Date of Birth*
First Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
First Clients Signature*
Second Clients Name

First Name*

Middle Name

Last Name*
Second Clients Date of Birth*
Second Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Third Clients Name

First Name*

Middle Name

Last Name*
Third Clients Date of Birth*
Third Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Fourth Clients Name

First Name*

Middle Name

Last Name*
Fourth Clients Date of Birth*
Fourth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Fifth Clients Name

First Name*

Middle Name

Last Name*
Fifth Clients Date of Birth*
Fifth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Sixth Clients Name

First Name*

Middle Name

Last Name*
Sixth Clients Date of Birth*
Sixth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Seventh Clients Name

First Name*

Middle Name

Last Name*
Seventh Clients Date of Birth*
Seventh Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Eighth Clients Name

First Name*

Middle Name

Last Name*
Eighth Clients Date of Birth*
Eighth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Ninth Clients Name

First Name*

Middle Name

Last Name*
Ninth Clients Date of Birth*
Ninth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Tenth Clients Name

First Name*

Middle Name

Last Name*
Tenth Clients Date of Birth*
Tenth Clients Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you had a facial before?*
No
Yes

Primary purpose for today's visit?
Do you wear contact lenses?*
No
Yes
Do you have asthma?*
No
Yes
Are you pregnant or lactating?*
No
Yes
Do you have any heart conditions?*
No
Yes
Do you have Diabetes?*
No
Yes
Are you currently menstruating?*
No
Yes
Are you currently using a tanning bed?*
No
Yes
Do you ever experience burning or itching on your skin?*
No
Yes

Please list any medications you are currently taking:
Are you using Retin A, Accutane, glycolic acids, or any topical prescription drugs for your skin?*
No
Yes

If yes, please list:

Are you allergic to anything?
Do you have a history of skin cancer?*
Are you currently undergoing chemotherapy or radiation therapy?*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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