New Client Facial Intake Form

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Skin Profile

Do you experience skin sensitivity?

Yes

No

Sometimes

If yes, please describe triggers (products, waxing, sun, etc.)

Current Routine

Please list any active ingredients or treatments you're currently using (ex. retinoids, salicylic acid, benzoyl peroxide, vitamin c, etc)

Skin Sensitivity

Does your skin react easily to skincare products?

Yes

No

Sometimes

Are you currently using or have recently used any of the following?

Health Factors

Are you currently pregnant or nursing?

Yes

No

Do you have any allergies to skincare ingredients, medications, or topical products?

Skin Goals

Photo Consent

Do you consent to before and after photos for treatment documentation?

Yes — internal records only

Yes — may be used for marketing or education

No

I confirm that the information provided is accurate and understand my esthetician will determine the safest treatment approach based on my skin condition and medical history.