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

Medical Information (Select All That Apply)

Other Medical Information Or Conditions

Current Medications & Supplements (List All)

Allergies & Sensitivities (List All)

Are You Pregnant Or Nursing?

Yes

No

Skin Type

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.

Signature

Parent/Guardian Signature

If client is under 18 years old, a parent or guardian must sign to provide consent.