Client Intake Forms Name * First Name Last Name DOB * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Checkbox * Check Any Of The Following Drugs/Medications You've Used Antibiotics Accutane Benzoyl Peroxide Retin A Differin Testosterone Progesterone Thyroid Medication Steroids Anything Else? List The Products You're Currently Using, Including Makeup * EG: Cleansers, Toners, Exfoliants, SPF, Topical Medications Are You Allergic to Any of the Following? * Sulfur Aspirin Latex None Any Other Allergies? Do You Smoke? * Yes No Do You Pick at Your Skins? * Yes No Sometimes Are You Currently Under a lot of Stress? * Do You Work Around Chemicals, Tars, Oils or Inks? * Yes No Do You Regularly Eat Any of the Following? Check all that Apply * Kelp Seaweed Sushi Salt Fast Foods Dairy Soy Protein Shakes or Bars Peanuts/ Peanut Butter List Any Medications or Supplements You're Currenlty Taking * Are You on Birth Control? What Method? * Are You Pregnant or Nursing? * Yes No What are Your Skin Care Concerns? Check any that Apply * Blackheads Whiteheads Pimples/Pustules Cysts Oily Skin Dehydrated Skin Dark Spots Age Spots Broken Capillaries Fine Lines/ Wrinkles Dry, Flaky Skin Sensititve Skin Razor Bumps Shaving Irritation Acne Rosacea What Else Have You done for Your Skin? * EG: Peels, Microdermabraion, Skin Cancer Removal Check any Medical Condition You May Have Has in the Past 2 Years * Diabetes Eczema Psoriasis Hepatitis Cancer Lupus Celiac Disease HIV/AIDS Hormone Problems Historectomy/Ovaries Removed Hemophilia Thyroid Problems Herpes Simplex/Cold Sores Anemia High Blood Pressure Epilepsy/Seizures None Are You Under a Dermatologists Care? * Yes No What Kind of Work do You do? How Did You Hear About Us? * Yelp Google Instagram Passing By Friend What Are Your Goals for Your Skin? * Anything Else You'd Like Me to Know? Consent & Agreement Treatment Overview * I understand treatments may include surface cleansing, mild chemical peels, steam, exfoliation, antibacterial and corrective serums, and extractions, lasting 20–45 minutes to balance, hydrate, and clear my skin in preparation for home care. I acknowledge all implements are single-use or sterilized per California Board of Cosmetology regulations. Pre-Treatment Confirmations * I have not been exposed to excessive sun or tanning, and my skin is not currently sensitive or irritated. I have avoided any chemical peel for at least 14 days. I have avoided facial waxing for at least 7 days. I have disclosed all health conditions, including cold sores or herpes simplex. I have informed my esthetician of any oral or topical medications I use, including retinoids (Retin-A, Renova, Differin, Tazorac) or Accutane. I understand that acne control and skin improvement require a series of treatments and strict adherence to my home care regimen. I understand that, if I follow home-care instructions carefully, any peeling or irritation should be minimal. Post-Treatment Warnings * I will avoid direct sun exposure and tanning booths for at least 3 days after treatment. will apply a broad-spectrum sunscreen (SPF 30 or higher) daily following treatment. I will refrain from picking or scratching my skin after treatment. Product Guidelines * understand clinical-strength products may tingle but should not be painful; if irritation occurs, I will discontinue use and contact my esthetician. I agree not to use any products not recommended by my esthetician during my acne program. I understand my home-care products are customized and should not be shared. I may return unopened products within 30 days for a full refund; opened or used products require prior authorization. Rescheduling & Late Policy * I will provide at least 24 hours’ notice to reschedule; late cancellations or no-shows may incur the full service fee unless the slot is filled. Arriving more than 20 minutes late may result in appointment cancellation and a missed-appointment fee. Photograph Consent * I consent to photographs of my progress for treatment monitoring. I consent to anonymous use of my photographs for promotional purposes, with no compensation expected. Agreement * I have read and understand all of the above and agree to follow all pre- and post-treatment instructions. Digital Signature * (Type your full name to sign below) Date of Consent * MM DD YYYY Thank you for submitting your forms!
