Today's date
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MM
DD
YYYY
Date of your first scheduled appointment at eleven esthetics
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MM
DD
YYYY
Name
First Name
Last Name
Preferred pronouns
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Date of birth
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MM
DD
YYYY
Email
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Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
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Emergency contact name
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Emergency contact number
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(###)
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How did you hear about eleven esthetics? (select one)
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Google
Yelp
Instagram
Facebook
Friend
Flyer
Walk-by
Gift certificate
Met the owner
Other
1) What do you consider as your primary skin type? (select one)
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Normal
Dry or dehydrated
Oily
Combination
Sensitive
2) How would you best describe your skin? (select one)
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I - Always burns; never tans
II - Burns easily; tans slightly
III - Burns moderately; tans gradually
IV - Seldom burns; always tans well
V - Rarely burns; deep tan
VI - Never burns; deeply pigmented
3) Which skin conditions would you like to improve? (select all that apply)
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Feel free to explain anything you checked off above
4) Are you currently under medical treatment for any skin condition?
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If yes, for what?
5) Have you ever had a facial before?
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If yes, when & what was your experience?
6) What would you like to achieve with your treatment today?
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7) What is your present skincare regimen? (select all that apply)
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Please list the above product brands/names if able
8) Have you ever used any of the following products on your skin? (select all that apply)
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If yes, when & for how long?
9) Have you ever had any of the following facial procedures? (select all that apply)
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If yes, how long ago?
10) Have you used any of the following hair removal methods within the past six weeks? (select all that apply)
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11) Have you ever had a reaction, allergic or otherwise, to any of the following? (select all that apply)
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If yes, please provide detail, including when
12) Do you wear contact lenses?
13) Do you currently have eyelash extensions?
14) Do you get sores/blisters (Herpes Zoster/Shingles)?
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15) Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?
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If yes, what are they?
16) Does your skin bruise easily?
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17) How does your skin heal? (select all that apply)
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18) Do you blush easily?
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If yes, what are the contributing factors? (select all that apply)
19) Do you ever sunbathe or go to a tanning bed?
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If yes, how often?
20) How would you describe your overall health? (choose one)
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Excellent
Good
Fair
Poor
21) Any personal or family history of skin cancer?
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If yes, please provide detail
22) Have you had any of the following, past or present? (select all that apply)
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If yes to any, please provide detail, including when
23) What medications (including OTC, vitamins, hormone replacements) do you currently take?
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24) Do any of the following conditions currently apply to you?
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25) Do you have any upcoming medical procedures or surgeries (within the next 4-6 weeks)?
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If yes, please provide detail below
1) How would you describe your general stress level? (select one)
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High
Medium
Low
2) Do you normally sleep well?
3) Do you have any food intolerances?
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If yes, for what?
4) Do you follow any special diet?
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If yes, what type of diet?
5) Do you have any upcoming vacations or occasions (within the next 4-6 weeks) where you will receive consistent sun exposure?
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If yes, please provide detail below.
6) In our treatment program, it may be necessary to recommend alterations or additions to your home skincare regimen. Would this be okay with you?
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7) Is there anything else related to your skin/skincare/general health not covered by this form that you'd like to share?
By checking the box below & submitting the contents of this form via the 'send' button, I agree to the terms of this New Client Intake & Consent Form
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