Client Intake Form New

Client Intake Form

Must be Completed 48 hours prior to Appointment

Dear valued client,

We are excited to welcome you to our beauty and skincare center. To ensure that you receive the best and safest treatment possible, we kindly request that you provide us with some essential information. Your privacy and comfort are our utmost priorities, and this information will be kept confidential.

Name *

First

Last

Email *

Phone *

Preferred Contact Method *

Phone
Email
Text

Medical History: Please inform us of any medical conditions, allergies, or medications you are currently taking, even if they may not seem relevant to your treatment. Your safety is important to us. *

Please explain if any, or None

Any Medical Conditions? *

If Yes , Explain or None

Any Allergies? *

If Yes , Explain or None

Have you had any recent surgeries, including plastic surgery, cosmetic piercings, or tattoos on the face? If yes, please provide details. Additionally, have there been any restrictions advised by your doctor that we should be aware of? If yes, please explain. Your safety and comfort are important to us. *

If Yes, please explain or None

Have you had any skin cancer? If Yes, Please explain. *

Yes and Explain or None

Are you taking medications that will affect your treatment ?

If Yes, please explain or None

Skin History: Help us understand your skin better by providing details about your skincare routine and any previous treatments.

Explain , If any.

Any Known Skin Sensitivities?

If Yes, please explain or None

Treatment Preferences: Let us know your preferences and goals for the treatment.

Desired Treatment: *

Ex: Facial ,HydraFacial, Keravive, Acne Treatment and etc.

Areas of Concern: *

Ex: Cheeks, Forehead, Chin and etc.

Consent and Agreement: I hereby acknowledge that I have provided accurate and truthful information to the best of my knowledge. I understand that the esthetician will use this information to tailor the treatment to my needs and ensure my safety. By signing below, I confirm that I grant San Francisco Esthetics permission to administer treatment based on the information I have provided. I understand that the accuracy and truthfulness of the information I have given are vital for tailoring the treatment to my specific requirements and ensuring my safety. I acknowledge that I am responsible for providing accurate details and that any undisclosed information could impact the effectiveness and safety of the treatment. *

Full Name ( First and Last)

Date / Time *

Date

Time

Signature "Full Name": *

Client Intake Form

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