top of page

Natural Skin Care

HOME
ABOUT
SERVICES
EARN $
GIFT CARDS
CONTACT
More

Use tab to navigate through the menu items.

Client Intake Form

Disclaimer:

Thank you for your interest in being a client of Studio Blu. This form is used to collect information about new clients and used for internal purposes only. The information you provide is confidential and will be treated accordingly.

Client Information

First Name

Last Name

Phone

How did you hear about us?

ALLERGIES & REACTIONS

HAVE YOU HAD ANY REACTIONS TO SKIN CARE PRODUCTS OR COSMETICS? IF YES, PLEASE DESCRIBE.

DO YOU HAVE ANY ALLERGIES? IF YES, PLEASE LIST KNOWN ALLERGIES.

DO YOU HAVE ANY HEALTH CONCERNS?

WHAT IS YOUR SKIN TYPE?

Normal

Oily

Dry

Combination

WHAT AREAS OF CONCERN DO YOU HAVE REGARDING YOUR SKIN? (check all that apply)

Breakouts/Acne

Blackheads/whiteheads

Excessive oil/shine

Sun damage

Uneven skin tone

Dull/Dry skin

Wrinkles/fine lines

Rosacea

Redness/ruddiness

Sun

Other: ______________

Broken capillaries

Sun damage

Wrinkles/fine lines

WHEN YOU GO OUT INTO THE SUN, DO YOU:

Always burn

Sometimes burn

Never burn

Usually burn

Rarely burn

SKIN CARE

HAVE YOU SEEN A DERMATOLOGIST WITHIN THE PAST YEAR?

Yes

If YES, please explain

DO YOU CURRENTLY USE ANY OF THE PRODUCTS LISTED BELOW? (check all that apply)

Accutane

Isotretinion

Scrub / Peel

Tretinoin / Avita

Adapalene

Renova

Topical Vitamin A

Other

Differin

Retin-A / Stieva-A

Topical Vitamin C

If YES, please describe:

HAVE YOU RECENTLY RECEIVED BOTOX, RESTYLANE OR COLLAGEN INJECTIONS:

Yes

IF YES, PLEASE SPECIFY:

ACKNOWLEDGEMENT & RELEASE

BY SIGNING THIS FORM, THE CLIENT AGREES TO THE FOLLOWING. I understand, have read and completed this questionnaire truthfully and agree to inform the technician of any changes in the above information. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

Your Signature

Thanks for submitting!