Client Intake Form

Please answer all questions truthfully and to the best of your knowledge. Your information will remain private between you and your esthetician.

Upon submission, one of our founding estheticians will contact you promptly to set up a complimentary consultation at your earliest convenience.

Name

First Name

Last Name

Phone Number

Current State of Your Skin

Describe what hardships you are facing with your skin: redness, irritation, sensitivity, breakouts (state location), swelling, ect.

Where would you like to see improvement with your skin?

Are you looking to improve texture, acne, redness/rosacea, fine lines, etc.?

What is your current regimen?

List all products you are currently using AM & PM.

Are you using any form of Retin-A

Are you using any prescription strength (from a doctor) Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? Please list all that apply.

Recent Services

Have you received any facial services in the last 30 days? If yes, please list all services.

Current Medications

Please list any and all medications you are currently using.

Any known allergies

Please list all internal and external allergies.

Health Conditions

Please list any and all current health conditions.

Topicals

Have you used or been prescribed any medications (topical or oral) for acne/acne control? If yes, please specify what and date last used.

Stress Level

Please rate stress level: low, med, high.

Female Client: Birth Control

Are you taking birth control. If yes, please specify.

Male Clients

What is your current shaving system: Razor/Wet Shave, Electric, N/A? Do you experience irritation from shaving?

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments and/or guidance received. The treatments and advice I receive here are voluntary and I release Suit Yourself and Sapphireskinco and Estheticians, Ciara Gutierrez and Ashley Whritenour, from all liability and assume full responsibility thereof.

I agree

Client Intake Form

Please answer all questions truthfully and to the best of your knowledge. Your information will remain private between you and your esthetician.

Faces on The Front Line