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Esteem Skincare Spa

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New Client

Facial Intake Form

First name

Phone

Last name

Date of Birth

Email

Would you like to be added to the email list? *

No

Yes

Emergency Contact Name

Emergency Contact Phone

Skin Concerns

Hyperpigmentation

Uneven tone/texture

Oiliness

Breakouts/acne

Dullness

Dryness

Redness

Sensitivity

Fine lines/wrinkles

Sunburn/damage

Health Concerns/Conditions

Pregnant/nursing

Diabetes

Thyroid

Cardiovascular

Cancer

Contagious infection/disease

Illness

Skin condition or other concerns

Elaborate on skin conditions or other health concerns:

If you are currently taking medication, please list:

If you are currently using a topical or oral skin treatment or have in the past, please list:

If you have any allergies to products, foods, etc., please list:

Have you seen a dematologist in the last year? *

No

Yes

When was your last facial treatment?

Please list the skincare products you use at home:

Does your skin burn easily in sunlight? *

No

Yes

Is the use of cold towels and jade rollers okay? *

No

Yes

Have you recently sunbathed or used a tanning bed? *

No

Yes

Do you prefer a quiet service? *

No

Yes

I declare that the info I’ve provided is accurate & complete.

Initials

Thank you for submitting!

2024 by Esteem Skincare Spa LLC

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