Esthetician Forms | Sanctuary PB

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First name*

Last name*

Email*

Phone*

Emergency Contact Name:*

Phone*

Are you currently under a doctor’s care?*

Yes

No

If yes, please explain

Do you have any medical conditions? (ex: diabetes, thyroid disorders, epilepsy, autoimmune disease, heart conditions, electrical implants) *

Do you take any medications or supplements? (Include birth control, Accutane, antibiotics, etc.) *

Have you ever taken Accutane?*

Yes

No

If yes, when did you stop?

Are you pregnant or breastfeeding?*

Yes

No

Skin History: How would you describe your skin? *

Oily

Dry

Combination

Normal

Sensitive

Main concerns:*

Acne

Dark spots / Hyperpigmentation

Aging / Wrinkles

Texture

Dehydration

Redness / Rosacea

Other:

Do you have any allergies? (skin, food, product ingredients)

Have you ever had reactions to skincare or cosmetics? *

Yes

No

If yes:

Have you received any of the following in the last 2–4 weeks?*

Chemical peel

Microdermabrasion

Micro-needling

Laser hair removal

Waxing

Botox / Fillers

Tanning (sun or spray)

None Apply To Me

Other:

Have you ever had a negative reaction to a facial treatment? *

Yes

No

If yes:

List all skincare products you currently use (cleanser, toner, serums, moisturizers, sunscreen, etc.)

How often do you wear SPF? *

Daily

Sometimes

Never

Sun exposure:*

Low

Moderate

High

Water intake:*

Low

Moderate

High

Stress levels:*

Low

Moderate

High

Do you smoke or vape?*

Yes

No

Do you pick at your skin?*

Yes

No

How many hours of sleep per night?*

Consent Form

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