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New Client Intake Form

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Occupation
Referred by
Email
How frequently do you receive skin care treatments? When was your last treatment?
How frequently do you receive massage treatments?
What kind of skin care treatments have you received? Include approximate dates.
What is your current skin care routine? Please be as descriptive as possible including strength of prescription products etc.
What do you hope to achieve during your scheduled session?
Do you have any known allergies or injuries that are relevant to your scheduled session?*
Are you currently under the care of a dermatologist or a physician? If yes, please list reasons:*
Informed Consent and Treatment Policies*
I agree to the informed consent and treatment policies.
I understand the treatment I will be receiving is for the purpose of relaxation and increased skin health. I understand a licensed esthetician/massage therapist does not diagnose illness or disease and the treatment I am about to receive is not a substitute for medical treatment or diagnoses.

I acknowledge the information I have provided on this form is correct and current to the best of my knowledge. It is my responsibility to inform my therapist of any changes to this information. If I experience any unusual discomfort and/or pain during my treatment it is my responsibility to inform my therapist so they can make the necessary adjustments.
Cancellation Policy*
I agree to the cancellation policy.
Please call or go online at least 24 hours in advance to re-schedule or cancel your session. Should you cancel within 24 hours of your scheduled treatment, you will incur 50% of the charge of the session. If you do not show up for your session, the full cost of the session is applicable and must be paid before another session is scheduled.
Name
This field is for validation purposes and should be left unchanged.

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