Client Intake Form

Today’s Date

Date*

Client’s Name

First Name*

Last Name*

Date of Birth

Date*

Gender

Phone Number

Please enter a valid phone number.*

Email

example@example.com*

Address

Street Address*

Street Address Line 2*

City*

State / Province*

Postal / Zip Code*

How did you hear about us?

What area is priority to treat at this time?

How long and how often have you used these methods?

Describe any reactions your skin has had to previous hair removal methods

Are you pregnant or planning to become pregnant?

Yes

No

Do you have an unusual skin condition, if so please explain

Client Signature

Sign below*

Clear

Upload

Relationship to client (if client is under 18)

Are you human?*

This field should be left blank

Today’s Date

Client’s Name

Date of Birth

Gender

Phone Number

Email

Address

How did you hear about us?

Desired Treatment Areas

What area is priority to treat at this time?

Previous methods of hair removal

How long and how often have you used these methods?

Previous electrolysis treatments?

Describe any reactions your skin has had to previous hair removal methods

Do you have any of the following conditions? If yes, please select them:

Implants

Are you pregnant or planning to become pregnant?

Menstrual History

Allergy Sensitivity

Current Medications

Do you have an unusual skin condition, if so please explain

Client Signature

Relationship to client (if client is under 18)