Aesthetician Intake Form & Consent | The Ritual Esthetics Room

First name

Last name

Phone

Emergency Contact Name & Phone

Relationship

What are your skin goals and areas of concern?

How would you describe your skin? (Dry, Oily, Combination, Changes Seasonally):

Have you had a facial before? If yes, when and what type?

Current skincare routine/products used:

Any harsh treatments in the last 30 days (chemical peel, laser, etc.)?

Have you had Botox, filler, facial surgery, or sinus surgery in the last 30–60 days? If so, what & when:

Facial tattoos in the last 30 days?

Have you had a cold sore in the last 30 days?

Sinus issues – current, ongoing, or seasonal?

Are you pregnant, trying, perimenopausal, menopausal, or experiencing hot flashes?

Are you currently under any medical treatments (such as chemotherapy, radiation, or anything that may cause skin sensitivity)? Please explain:

Are you currently taking any medications or using any medical devices (including implanted devices)? If yes, please provide details below.

Thyroid issues?

Claustrophobia?

Do you experience TMJ or jaw pain?

Sensitivities to light, touch, sound, or smell? Please explain:

Allergies

Contact lenses?

Hair extensions?

Do you give permission for before/after or during-treatment photos or videos to be taken and used?

Yes, may be used publicly on website, social media, or marketing materials

Yes, for educational purposes only (not publicly posted)

No, I do not consent to photos or videos being taken or used

Signature

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Date

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