Client Intake Consent Form

Collect a client's relevant medical history and informed consent before performing a facial or aesthetic treatment, including allergies, medications, and recent procedures.

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Name

Nombre

Apellido

Date of Birth

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency Contact

Nombre

Apellido

Emergency Contact Phone Number

Are you pregnant, breastfeeding, or nursing?

Yes No

Are you currently taking any prescribed medications (such as antibiotics, blood thinners, acne medications, anything from a dermatologist, etc.)? If yes, please list them below:

Do you have any known allergies/skin sensitivities? Please list:

Are you currently using Retinol, Retin-A/Tretinoin, Adapalene, or any Vitamin A derivatives?

Yes No

If so, how recent/how often?

Have you recently received Botox/Dermal Fillers?

Yes No

Have you recently received a chemical peel or laser treatment?

Yes No

Did you undergo any major surgery in the past 90 days? If yes, please describe:

I declare that the information provided is true and complete to the best of my knowledge.

Date

Signature

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Client Intake Consent Form

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