Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Med Spa / Aesthetics Intake Form
Your information
Client Information
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Aesthetic Areas of Concern
Treatment Goals & Expectations
Fitzpatrick Skin Type
Prior Aesthetic Treatments
Additional details
Injectable History (Botox/Filler)
Current Skincare Regimen
Sun Exposure & Tanning History
Contraindication Screening
Accutane & Medication History
| Medication | Dose | How often |
|---|---|---|
Allergy Assessment
| Allergy | Reaction |
|---|---|
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Consent & Signature
Date
Med Spa / Aesthetics Intake Form template from formisoft.com. formisoft.com/intake-templates/med-spa-intake