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Esthetician Client Intake Form

Learn each client's health history, skin type and care routine before their first facial or body treatment. Includes an acknowledgment signature for your studio or spa.

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Client's name

Nombre

Apellido

Gender

Female Male Non-binary Prefer not to say

Date of birth

Phone number

Email address

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Marital status

Single Married Divorced Widowed Domestic partnership

Occupation

Company name

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

Allergies Asthma Diabetes High blood pressure Heart condition Epilepsy None

Skin type

Normal Dry Oily Combination Sensitive

How does your skin heal?

Quickly Normally Slowly Scars easily

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, regularly Yes, occasionally No

Are you pregnant?

Yes No Not sure

Are you trying or planning to become pregnant?

Yes No Prefer not to say

Are you taking any contraceptive pills?

Yes No Prefer not to say

Are you breastfeeding?

Yes No Not applicable

Do you consume caffeinated drinks?

Yes, daily Yes, occasionally No

Do you wear contact lenses?

Yes No Sometimes

Are you currently on any kind of diet?

Yes No Occasionally

Have you undergone any surgeries?

Yes No Prefer not to say

Client acknowledgment

Client signature

Sign here

Date signed

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