Skin By Francaise — Licensed Medical Esthetician

Skin By Francaise

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New Clients

Client Intake + Skin Consultation Form

Please complete this form before your appointment so I can customize your treatment for the best possible results.

Personal Information

Full Name

Phone Number

Email Address

Date of Birth

Address

City

State

Zip

Occupation (Optional)

What Brings You In Today?

Check all that apply

Acne / Breakouts Congestion / Blackheads Aging / Fine Lines Skin Tightening Hyperpigmentation Melasma Rosacea / Sensitivity Dryness / Dehydration Texture / Acne Scarring Preventative Aging Relaxation / Self Care

Other

Current Skin & Health History

Skin Conditions

Sensitive Skin Active Acne Eczema Psoriasis Rosacea Excess Oil Excess Dryness Hyperpigmentation Melasma Keloid Scarring Cold Sores / Herpes Simplex

Medical Conditions

Autoimmune Condition Thyroid Condition Diabetes Heart Condition Asthma Epilepsy Blood Clotting Disorder Pregnant or Nursing

Allergies (Skincare, Food, Latex, Medications)

Current Medications or Supplements

Are you currently using:

Retinol / Retin-A Accutane (past 12 months) AHAs / BHAs Prescription Acne Medication None

Under physician care?

Yes No

Physician Name & Phone Number

Recent Treatments

Have you had any of the following within the last 4 weeks?

Botox Fillers Laser Treatments Microneedling Chemical Peels Facials

Other Recent Treatments

When?

Lifestyle & Skin Habits

How many glasses of water do you drink per day?

Do you drink soda or sweetened beverages?

Yes No

If yes, what kind and approximately how many per day?

Do you smoke or vape?

Yes No

Alcohol consumption

None Socially Weekly Frequently

Do you wear SPF regularly?

Yes No

How would you describe your stress levels?

Low Moderate High

Treatment Preferences

Are you comfortable with:

Extractions Chemical Peels Microneedling LED Therapy Reiki / Energy Work Before & After Photos

Your Skin Goals & Expectations

What are your main skin goals and what would you love to improve most about your skin?

Is there anything you would like me to know before your appointment?

What are your expectations for your treatment experience and results?

I understand that results vary depending on skin type, lifestyle, consistency, and home care. I have disclosed all known medical conditions, medications, allergies, and recent treatments to the best of my knowledge. I consent to treatment performed by Skin by Francaise.

I Agree

Client Signature (Type Full Name)

Date

Consent

Photography Consent

Please indicate your preferences regarding photography during treatments.

Photography Consent

I consent to before and after photos for treatment tracking purposes. I consent to photographs/videos being used for educational or marketing purposes by Skin by Francaise. I do not consent to photography or social media use.

Full Name

Date

Skin By Francaise

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