YOUR COMPANY NAME

FACIAL CLIENT INTAKE FORM

Client Name Age Treatment Day & Time
Paul George 38 05/07/2024 15:30

Address: 124 Great Boulevard, 35454 Jacksonville Treatment interested in

Phone: (555) 1052-525-856 Microdermabrasion

Email: paul34george@newemail.com

Have you ever had facial treatment before? ☐ YES NO Do you suffer from

Hydrating facial, 2 months ago ☐ Eczema

How much UV exposure do you get? ☒ Reasonable ☐ Plenty ☐ Abrasions

Do you smoke? ☒ YES 12 Cigarettes per day ☐ NO ☒ Bruises

How many glasses of water do you drink per day? 6-8 ☐ Broken capillaries

How often do you exercise? Every Monday and Friday, 1.5 hours ☐ Cuts

How would you estimate your stress level (1 to 10)? 5 ☒ Hematoma

How many hours of sleep do you get per night? 7-10 ☐ Active acne

ESTIMATE YOUR SKIN Excellent Fair Poor ☒ Cellulite

Moisture content ☒ ☐ ☐ ☐ Whiteheads

Muscle tone ☐ ☒ ☐ ☐ Blackheads

Elasticity ☐ ☐ ☒ ☐ Dehydration

Healing ability ☐ ☐ ☒ ☐ Psoriasis

Fair Medium Dark ☐ Circulation problems

Skin tone ☐ ☐ ☒ ☐ Herpes

What would you like to achieve with your treatment? ☐ Loss of sensation

To remove the outermost layer of dead skin cells. ☐ Fungal condition

Please select the box that applies to you: ☐ Skin disease/lesions

☐ I never tan ☐ I tan with difficulty ☐ Average tanning ☐ Fever blisters

☐ Easily tan, rarely burn ☒ I never burn ☐ Seborrhea

Please list all medications, supplements, allergies or recent surgeries: ☐ Varicose veins

Medications: None. Supplements: Daily multivitamin. Allergies: None. ☐ Hyper pigmentation

Recent Surgeries: Appendectomy (6 months ago).
☐ Hypo pigmentation

By signing this form, the client agrees to the following: CLIENT SIGNATURE
1. I understand that I am providing truthful and accurate information on this questionnaire.
2. I agree to inform the technician of any changes in the information provided above.
3. This form constitutes full disclosure and supersedes any previous verbal or written disclosures.

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