Client Intake Form

First Name

Last Name

Email

Phone

Date Of Birth

Month

Day

Year

Contraindications

Accutane Within 6 Months Of Treatment

Active Herpes Simplex (Cold Sores)

Neurotoxin Injectables Or Filler Within Two Weeks Of Treatment

Sunburn

Topical Vitamin A Derivatives Within 5 Days Of Treatment

Other Medical Information Or Conditions

Current Medications & Supplements (List All)

Allergies & Sensitivities (List All)

Are You Pregnant Or Nursing?

Yes

No

Skin Concerns

Current Skincare (List All Products)

Massage Preference

Hand

Foot

Scalp

Consent To Photos For Client Records

Yes

No

I have completed this form to the best of my ability/knowledge and agree to inform my aesthetician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I agree to waive all liabilities toward my aesthetician (AKAYSKIN LLC) for any injuries or damages incurred due to any misrepresentation of my health history.