Intake Form - SKN Clinic

NEW CLIENT INTAKE FORM

Please fill out the new client intake form, this will speed up the process on your first visit with us. Once completed, a SKN Clinic Manager will contact you with availability options for your in-person consultation. We look forward to seeing you soon!

Are you 18 or older? *

Client Details

First Name *

Last Name *

Phone number *

Email *

Confirm Email

Would you like to receive Monthly Promotions & Loyalty Perks emails? *

Yes, sign me up
No thanks

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Emergency Contact & Relation *

Emergency Contact Phone Number

How would you like us to contact you? *

I prefer a phonecall
I prefer to be emailed

How did you find us?

Client Expectations

Medical History

Are you currently on/have you ever taken any of the following medications?

Paragraph Text

Are you currently pregnant and/or breastfeeding?

Have you ever been diagnosed and/or treated for cancer?

How is your digestive health? Do you experience constipation, bloating or other digestive symptoms? Please explain

Are you currently taking any herbal or nutritional supplements?

Do you suffer from a hormonal imbalance?

Are you currently on hormonal replacement therapy (HRT)?

Do you bruise easily?

Do you wear contact lenses?

What best describes your skin?

Do you regularly suntan outdoors or use a tanning bed?

Do you wear sunscreen daily?

What best describes your skin's reaction during prolonged UV/Sun exposure?

Treatment History

Date of last treatment

Expectations

Skincare History

Do you use any topical actives in your skin care regimen, including any of the following, on a regular basis?

AHAs (Alpha Hydroxy Acids) including Glycolic / Lactic / Fruit Acids
Vitamin A (Tretinoin / Reinoic Acid / Retinol / Retinyl Palmitate / Other)
Benzyl Peroxide
Hydroquinone
BHA (Beta Hydroxy Acid) including Salicylic Acid
Vitamin C (Ascorbic Acid)
Kojic Acid / Azelic Acid

Have you ever had a negative reaction to a skin care product?

Lifestyle & Diet

How would you rate your stress level?

Low
Medium
High

How would you rate your current diet?

Good
Adequate
Needs Improvement

Do you normally sleep well?

Do you exercise regularly?

Do you smoke (tobacco)?

Do you have food intolerances?

Additional comments

______________________________________

Would you like the Empower Your SKN Loyalty Program sign up link? *

Yes, send me the sign up link!
No thanks. I understand loyalty points cannot be retroactively applied.

We have a FREE loyalty program where you can earn points with every dollar spent and use those points for free products and treatments. No strings attached! Would you like to receive an email with details about how to sign up?

______________________________________

Cancellation Policy

Once we have confirmed your appointment, we require a minimum of 24hrs notice before your appointment time for cancellations or changes for appointments up to 60 minutes in length. For appointments longer than 60 minutes, we require 48hrs.

Failure to provide adequate notice, or no-showing, will result in a $50 late cancellation fee and no-shows will also be required to pay in full in advance to re-book.

All new clients must provide a credit card number to book their first appointment. Also, clients booking Acupuncture or multiple appointments (for themselves and a friend) will be required to provide a credit card to hold their spots.

I have read and understand the cancellation policy *

I agree

PLEASE SIGN HERE *

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At SKN Holistic Rejuvenation Clinic, we offer clients the most complete level of service available. Our highly trained and insured skincare professionals are welcoming and easy to deal with; and our beautiful, private clinic is the perfect environment to provide clients with the highest quality of service possible.

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