Client Intake Form

Client's Name

Gender

Male Female

Date of Birth

Phone Number

Email Address

Address

Civil Status

Single Married Divorced Widowed

Occupation

Company Name

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

How do you take care of your skin at home?

How do you take care of your skin at work?

Do you consume alcohol?

Yes No

Are you pregnant?

Yes No

Are you trying or planning to be pregnant?

Yes No

Are you taking any contraceptive pills?

Yes No

Are you breastfeeding?

Yes No

Do you consume caffeinated drinks?

Yes No

Are you wearing any contact lenses?

Yes No

Are you currently under any kind of diet?

Yes No

Have you undergo any surgeries?

Yes No

What beauty or cosmetic products you're currently using?

Product Name

Purpose

Frequency

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

Product/Medication Name

Purpose

Frequency

Terms & Conditions

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.

I understand and agree to the terms and conditions. *

Client Signature:

Date Signed

Esthetician Client Intake Form