First name

Last name

Birthday

Month

Day

Year

Phone

If other, please specify:

What are your current skincare goals or concerns?

What skincare products are you currently using? (Cleanser, moisturizer, SPF, treatments, etc.)

Are you currently using:

Retinol

Vitamin C

AHAs/BHAs

Prescription skincare (Accutane, Tretinoin, etc.)

How often do you exfoliate?

Daily

A few times a week

Occasionally

Never

Are you currently pregnant, nursing, or trying to become pregnant?

Yes

No

Do you have any known allergies or sensitivities (including but not limited to skincare, latex, or other)?

Are you under the care of a dermatologist or physician for any skin conditions?

Yes

No

Do you have any medical conditions we should be aware of (e.g., diabetes, heart issues, epilepsy, etc.)?

Is there anything else you'd like me to know to help personalize your experience?

I understand that services provided are not a substitute for medical care.

I acknowledge that I’ve disclosed all relevant health information.

I give consent to receive skincare services.

I have read and understand the cancellation policy.

I authorize and give consent for the use of photos taken during the service to be used for any and all social media and advertising purposes.

New Client Esthetics Form