Esthetician Client Intake Form

Information you will need

• ESTHETICIAN ONLY: What's the esthetician's name?
• CLIENT ONLY: What's your name?
• What's your street address?
• What's your city?
• What's your state?
• What's your phone number?
• What's your gender?
• Would you like to receive emails from the esthetician/spa?
• Do you have any reactions to skin care products or cosmetics?
• What are the reactions you've had?
• Do you have allergies?
• What are your allergies?
• Esthetician af image
• How did you hear about the esthetician/spa?
• What are your health concerns?
• Do you have other health concerns your esthetician should know about?
• What are your other skin concerns?
• What is your skin type?
• How often do you get sunburnt when exposed to the sun?
• What kind of skin care did you receive?
• Have you seen a dermatologist within the past year?
• Which of the above products do you use?
• What facial injections did you recieve?
• Have you received facial injections in the past 6 months?

…and 29 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.