Esthetics Intake Form

Esthetics Intake Form
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email *
example@example.com
What is your Gender? *

Female Male
Date of Birth *

Month Day Year
Date
Emergency Contact *
Emergency Contact Phone Number *
Medical

Health History
Within the last year, have you been under a dermatologist or other physicians care? If yes, please explain: *
Within the last year, have you undergone any surgeries? If yes, please explain: *
Have you had any health problems in the past or present? If yes, please explain: *
Do you smoke? *

Yes No
Are you diabetic? *

Yes No
Are you currently using blood thinners? *

Yes No
Do you wear contacts? *

Yes No
Do you use sunscreen? *

Yes No
Do you have metal implants, a pacemaker or body piercings? *

Yes No
Do you have any skin conditions on your face or body such as psoriasis or eczema? If yes, please explain: *
Females Only Are you pregnant?

Yes No
Skin
Please select your skin type:

Normal Dry Sensitive Oily Combination Acne Prone
What skin care products are you currently using?

Soap Cleanser Toner Moisturizer Exfoliater Eye Products Masque
Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? If yes, please explain:
Do you have a tendency to redness?

Yes No
Do you ever experience skin breakouts?

Yes No
Do you ever experience oily shine during the day?

Yes No
Do you ever experience a reaction to any of the following?

Cosmetics Fragrance Hydroxyl acids Sunscreens None
Do you experience these conditions on your skin?

Flakiness Tightness Sensitivity None
What are your skin care goals?
Wax
Have you ever had any adverse reactions to waxing? If yes, please explain:
When did you last shave?
How often do you shave?
Do you have any tendencies to any of the following:

Ingrown hair Scarring Bumps/hives Hyperpigmentation Bruising None
Please check if you are currently using or have used any of the following products within the last 3 months:

Acutane Retin-A Daily dose(s) of Aspirin Renova Glycolic Acid Pro-Active skincare Any form of Vitamin C None
(Female clients) When is your next menstrual cycle due to begin?
(Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)
Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.
Should be Empty:

Esthetics Intake Form

Medical

Skin

Wax