Client Intake Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Skin Care

1. Would you classify your skin type as sensitive, acne prone or normal (no sensitivities)? *

2. What would you like to achieve from your treatment(s)? *

3. Have you ever had a facial treatment before? *

Please give details (including when): *

Fitzpatrick skin types:
1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

4. Which of the above skin types would you say is closest to your skin? *

5. Which of the following best describes your skin type? *

6. Do you have any special skin problems or concerns pertaining to your face or body? *

Please give details: *

7. Have you ever had chemical peels, laser or microdermabrasion? *

Please give details (including when): *

8. Have you ever used Retin-A, Renova, Adapalene Hydroxyl Acid (AHA) or Retinol/vitamin A derivative products? *

Please give details (including when you last used these): *

9. Have you ever had any acne medication(s)? *

Please give details (including when you last used these): *

10. What skin care products are you currently using? (List brand where known): *

11. Have you used any of the following hair removal methods in the past 6 weeks?

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories

12. What areas of concern do you have regarding your skin? Please check all that apply: *

If Other, please specify:

13. Have you ever experienced any skin sensitivities to any cosmetics, food products (citrus, berries etc.), medicine, fragrances, sunscreens, latex etc.? *

Please specify: *

14. Do you wear SPF daily? *

15. Have you ever had Botox, Restylane or Collagen injections? *

Please specify (including when): *

Are you currently pregnant, or trying to become pregnant? *

Are you nursing? *

Any menopause problems? *

ANY ADDITIONAL NOTES/COMMENTS:

Consent

I understand, have read and completed this intake form 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 any treatments received. The treatments I receive here are voluntary and I release AESTHETICSBYTINA LLC from liability and assume full responsibility thereof.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign