Client Intake & Consent Form: Facial Treatment

Please complete this form before your appointment. All information is strictly confidential and helps me provide the safest, most personalized experience for you.

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Full Name ^*

Phone ^*

Email ^*

Emergency Contact — Name & Phone ^*

Date of Visit ^*

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Health & Skin History

Do you have any known allergies? ^*

Do you have any skin conditions or sensitivities? ^*

Rosacea, eczema, active breakouts, sensitivity etc.

Are you currently using any of the following? ^*

Please select all that apply

Accutane/Isotretinoin

Retin-A/Retinoids

Prescribed Topical Cream

None of the above

Are you currently pregnant? ^*

Yes

Have you ever had any reaction to skincare products? ^*

If yes, please describe the reaction and products used

Have you had recent Botox or facial fillers? ^*

within 2 weeks

Yes

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Client Intake & Consent Form: Facial Treatment

Health & Skin History

Skin Profile

Consent & Acknowledgment

Thank you! 🙌