esthetician

"Maintaining Radiant Skin, Enhancing Natural Beauty"

Client Intake Questions

Client Intake Sheet for Skin & Body Care 

 Name: ________________________________________________________________________  

Phone: _______________________________________________________________________      

Email: ________________________________________________________________________        [ y/n ] I’d like to receive monthly texts updates for promotions & service specials

 Line of work: __________________________________________________________________  

Date of last facial: ______________________________________________________________ 

Present skin condition: [ Dry ] [ Oily ] [ Normal ] [ Acneic ] [ Inflammed ] [ Rash ] [ Sunburned ]
[ Other ] _____________________________________________________ 

Daily Facial Regimen; 

 [ y/n ] Make-up Remover :____________________________________

 [ y/n ] Cleanser : _____________________________________________

 [ y/n ] Exfoliator : _____________________________________________

 [ y/n ] Toner : ________________________________________________

 [ y/n ] Masque : _____________________________________________ 

 [ y/n ] Serum : _______________________________________________

 [ y/n ] Moisturizer : ____________________________________________ 

 [ y/n ] Sun Protection : ________________________________________ 

 [ y/n ] Make-up : _____________________________________________

 [ y/n ] Brushes, Machines, Tools : _______________________________

 Please note your contraindications. 

 Medications: [ Accutane ] [ Blood Thinners ] [ Hormones ] [ Insulin ]

 [ Chemotherapy ] [ Antibiotics ] [ Thyroid ] 

 [ y/n ] Topical Prescriptions by Dermatologist:__________________________________

 [ y/n ] Allergies to [ Herbs ] [ Cosmetics ] [ Food ]:______________________________

 [ y/n ] Pregnant : _________ Weeks

 [ y/n ] Recent Surgery : ______________________________________________________

 [ y/n ] Metal Implants : ______________________________________________________

 What is your daily consumption of; 

Water: ________ ou. Tea: ________ ou. Coffee: ________ ou.
Juice: ________ ou. Soft Drink: ________ ou. Alcohol: ____% _____ ou. 

 How did you hear of Jessika’s Aware Skincare? ________________________________________________________________________________

 Thank You!

The information I have offered is true & I release liability of Jessika’s Aware Skincare to perform the agreed Facial procedure in which we have discussed the strength, process, & at-home care.
X __________________________________________________________________________________

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