Facial Intake Form – Indigo Salon and Day Spa

Esthetician Client Intake Form

Name
First Last
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Medical Information
Are you currently or within the last year under a doctor's care?
If yes, please explain:
Please specify any health problems:
Please list all medications and vitamins:
Have you undergone surgery recently?
If yes, please explain:
Do you have metal implants?
Are you pregnant or do you think you might be pregnant?
List any/all allergies or sensitivities:
Do you have any special skin problems? Please specify.
Do you ever experience skin break-outs?
Do you blush easily?
Do you have a redness tendency?
Do you sunburn easily?
What is your massage preference?
Daily Face Care:
- Soap
- Cleanser
- Toner
- Scrub
- Masque
- Moisturizer
- SPF
- Other
What water temperature do you cleanse with?
Do you exercise regularly?
Consent
By checking this box, I agree with the following:
I understand that if I have any skin concerns, I will address these with my skin care therapist. I give permission to my skin care therapist to perform the procedure we have discussed and will hold him/her and his/her company harmless from any liability that may result from this treatment. I have accurately answered the questions above including all known allergies, prescription drugs, conditions or products I am currently ingesting or using topically. I understand my skin care therapist will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the skin care therapist immediately.
Phone
This field is for validation purposes and should be left unchanged.

Esthetician Client Intake Form

Medical Information