Client Intake Form

Your Information

First name

Last name

Phone

Emergency Contact

Who would you like us to contact in case of an emergency?

Name & Phone Number

What are your primary skin concerns & treatment goals?

(e.g., acne, dryness, sensitivity, aging, pigmentation)

What is your current skincare routine?

Briefly explain your routine and list the products you use regularly (cleanser, moisturizer, sunscreen, etc.).

Skin History

If any of the above apply, or if you have any other professionally diagnosed skin conditions, please provide details below.

Have you ever had any adverse reactions to skincare products or treatments?

Please list any known allergies or sensitivities.

Health History

If any of the above apply, or if there are other health conditions I should be aware of, please provide details below.

Are you currently using or undergoing treatment with any of the following?

Please Review and Agree to the Following

By checking this box, I agree to provide at least 24 hours’ notice for cancellations or rescheduling. I understand that less than 24 hours' notice will result in a 50% charge, and no-shows will incur a 100% fee.

By checking this box, you acknowledge that Le Petit Spa Skin Studio will not be held liable for any complications that may occur.

I confirm that, to the best of my knowledge, I have provided an accurate account of my medical history, including all known allergies and any prescriptions or products I am currently using, whether ingested or topical.