Esthetician Client Intake Form

Full Name *

Date of Birth *

Contact Information (Phone or Email) *

Emergency Contact (Name and Phone Number)

What is your primary reason for today's visit? (e.g., skincare consultation, facial, acne treatment, anti-aging) *

Do you have any specific skincare goals or areas of concern?

How would you describe your skin type? *

If you selected 'Other', please specify

Are you currently taking any medications or using topical prescriptions? *

If yes, please list your medications or topical prescriptions

Do you have any known allergies or skin sensitivities (e.g., fragrances, ingredients)?

Have you had any of the following procedures recently? (Check all that apply)

If you selected 'Other', please specify

Are you currently pregnant or nursing? *

Do you have any additional comments or concerns?

Signature of Client *

Date of Submission *