Facial Client Intake and Consent Form

Understand each client's skin before their appointment: medical history, allergies, current products, lifestyle habits and treatment goals, all closed with a signed consent. Built for spas and skincare studios.

Use this template

In the Claude connectors directory

Today's Date

Name

First Name

Last Name

Date of Birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Occupation

How did you hear about Flawless Fix?

If referred, by who?

Emergency Contact Name

First Name

Last Name

Emergency Contact Number

Have you seen a Dermatologist in the past year?

Yes No Not sure

If yes, list the Dermatologist's name, contact info and reason for visit:

Are you currently under the care of a physician or skin care therapist?

Yes No Not sure

If yes, provide name and contact number.

Any recent surgery, including plastic surgery?

Yes No Prefer not to say

If yes, please explain:

Do you have or have ever had any of the following?

If other, please explain:

Any known allergies (check all that apply)?

Please list any other allergies or sensitivities:

List any medications, supplements, or herbal remedies you currently take (enter n/a if none):

Do you (check all that apply)?

Smoke Drink alcohol Exercise regularly Wear contact lenses Tan outdoors or use tanning beds

Do you suffer from sinus problems?

Yes No Occasionally

Have you ever experienced claustrophobia?

Yes No Not sure

What is your current stress level?

Low Moderate High Very high

Are you pregnant or breastfeeding?

Pregnant Breastfeeding Neither

Are you taking birth control or hormone replacement?

Birth control Hormone replacement Neither

Have you had a facial treatment before?

Yes No Not sure

If yes, when was your last facial or skin treatment?

Are you currently using any products that contain or are you taking any of the following?

Have you received any of these skin care treatments?

If you checked any of the above, please select one:

Within the last month One to three months ago Over three months ago

Have you ever had an adverse reaction after using any skin care product?

Yes No Not sure

If yes, please check all that apply:

If yes, which products or brands?

Have you had Botox or other injectables?

Yes No Prefer not to say

If yes, date of last treatment?

What do you consider your skin type?

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?

Hyperpigmentation Hypopigmentation Both Neither

Do you have frequent breakouts?

Yes No Occasionally

What skin care products do you currently use?

What is your daily skin care regimen?

Do you use sunscreen?

Daily Sometimes Rarely Never

What are your specific concerns at this time regarding your skin?

What is your skin care goal?

Indicate what services or areas for which you are interested in (check all that apply):

Classic facial Chemical peel Dermaplaning Microdermabrasion Waxing Brows and lashes

Consent

Signature

Sign here

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