Esthetician Client Intake Form

Client's Name

First NameLast Name

Gender

MaleFemale

Date of Birth

Date

Phone Number

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Civil Status

SingleMarriedDivorcedWidowed

Occupation

Company Name

Do you have any of the following conditions? If yes, please select them:

Skin condition

How does your skin heal?

How do you take care of your skin at home?

How do you take care of your skin at work?

Do you consume alcohol?

YesNo

Are you pregnant?

YesNo

Are you trying or planning to be pregnant?

YesNo

Are you taking any contraceptive pills?

YesNo

Are you breastfeeding?

YesNo

Do you consume caffeinated drinks?

YesNo

Are you wearing any contact lenses?

YesNo

Are you currently under any kind of diet?

YesNo

Have you undergo any surgeries?

YesNo

What beauty or cosmetic products you're currently using?

Are you taking any medications that is related to cosmetic or skin improvement?

I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information.

I confirm that all information in this form is true and accurate.

I confirm that if I hold some important information and complications happened, the clinic will not be liable.

I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

Client Signature

Date Signed

Date