Client Intake Form

Personal Information

Date:*

First name*

Last name*

Email*

Phone*

Birthday*

Year

Month

Day

Address*

Emergency contact name and relationship*

Emergency contact phone*

Medical Information

Are you taking any medications or supplements?*

Yes

No

If yes, please list name and use:

Are you currently pregnant or breastfeeding?*

Yes

No

Do you have any known medical conditions/illnesses/diseases?*

Do you have any allergies or sensitivities?*

Yes

No

If yes, please list:

Any recent tanning (beds, sprays, outdoors)?*

Any recent cosmetic surgeries, skin treatments, botox, or dermal fillers?*

Yes

No

If yes, when and what was performed?

We provide a systematic approach including clinical treatments and at home care to transform your skin and maintain results. Are you committed to care for your skin?*

Yes

No

Signature*

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House of Beauty

9-440 Ecclestone Drive, Bracebridge ON, P1L 1Z6

houseofbeautymuskoka@gmail.com

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