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CLIENT INTAKE FORM 

Disclaimer: Thank you for your interest in being a client of ANEW This form is used to collect information about new clients and used for internal purposes only. The information you provide is confidential and will be treated accordingly. 

By signing this form, the client agrees to the following:

I understand, have read, and completed this intake form truthfully and agree to inform the technician of any changes in the above information. 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 skin care professional from liability and assume full responsibility thereof. 

Date: April 29, 2025

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Second Participant's Date of Birth*
Second Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Third Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Third Participant's Date of Birth*
Third Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Fourth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Fifth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Sixth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Seventh Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Eighth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Ninth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Tenth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
Products + Facial History
Do you consent for images and/or videos of you to be marketing and/or promotional purposes?*
Yes
No
When was your last facial? *
What products are you currently using? *

List brands or products that you are currently using
Are you currently taking any medications *
No
Yes

What medications? *
I consent to the facial that anew.+ performs*
Yes
I have read and understand the cancellation policy*
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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 Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Would you like to receive email promotions and updates?*
Yes
No

Birthday

How did you hear about us?

Allergies & Sensitivities: 

Have you had any reactions to skin care products or cosmetics?*
Yes
No

If yes, please describe:
Do you have any allergies?*
Yes
No

Please list any known allergies:
Do you have any other health concerns we need to know about?*
Yes
No

If yes, please describe:
Skin type:
Normal
Oily
Dry
Combination
What areas of concern do you have regarding your skin? (check all that apply)
Breakouts/Acne
Uneven skin tone
Excessive oil/Shine
Dull/Dry skin
Broken capillaries
Dehydrated
Blackheads/Whiteheads
Sun damage
Wrinkles/Fine lines
Rosacea
Redness/Ruddiness
Sun, liver, brown spots
Other:

If other, please list:
When you go out into the sun, do you:
Always burn
Sometimes burn
Never burn
Usually burn
Rarely burn
Have you seen a dermatologist within the past year?*
Yes
No

If yes, please explain:
Do you currently use any of the products listed below? (check all that apply)
Accutane
Isotretinion
Scrub/Peel
Tretinoin / Avita
Adapalene
Renova
Topical vitamin A
Differin
Retin-A / Stieva-A
Topical vitamin C
Other:

If other, please list:

If yes, please describe:
Have you recently received Botox, Restylane, or Collagen injections?*
Yes
No
Do you have facial threads?*
Yes
No

If yes, please specify:
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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