Client Intake Form-TAG Esthetics

Client Intake Form

Date of Intake Form

What is your first name?

What is your last name?

What is your email address?

What is your best contact phone number?

What is your mailing address?

What are your skin concerns? (Check all that apply.)

Acne

Blemishes

Dehydration (feels tight)

Dryness (feels tight and is also flaky)

Oiliness

Brown/sun spots

Clogged pores/blackheads

Easily irritated by products/sensitivity

Lines & wrinkles

Large pores

Age prevention/keeping skin healthy

Redness/sensitivity

Rosacea

Eczema

Loss of tone/lack of firmness

How oily is your skin? (Check one.)

Oily year round

Combination in the summer, normal in the winter

Combination (t-zone oil) year round

Normal year round

Oily in the summer, combination in the winter

Normal in the summer, dry in the winter

Combination year round

Dry year round

What types of blemishes do you get most often? (Check all that apply.)

Cysts (hard, sore "underneath" blemishes under the skin that rarely suface)

Pustules (red, inflamed, traditional "zits" that usually surface)

Whiteheads/Closed Comedones (non-sore, clogged bumps under the skin)

Other

How often do you get blemishes? (Check one.)

Never (this is not an issue for me)

Occasionally (once a month or less)

Often (about one per week)

Daily ( a new blemish appears every day)

Rarely (once in a while)

Occasionally (a few a month)

Often (about 2-3 breakouts per week)

Where do you get the majority of your blemishes? (Check one.)

Forehead

Nose

Cheeks

Back

Do you have any allergies?

Who referred you to TAG Esthetics?

Please upload images of your makeup-free face and neck (front & both sides)

Please upload images of your make-up free face and neck (front & both sides)

Additional notes/comments