Client Intake Form

Thank you for booking!

Please take a moment to fill out the following information so we can best serve you.

First name

Last name

Email

Reasons for booking your treatment:

Reduce breakout activity

Reduce oiliness and congestion in pores

Soothe redness or sensitivity

Improve skin texture or pigmentation

Reduce dry skin or dead skin buildup

Maintain healthy skin and prevent future skin concerns

I have chronic pain or headaches and would like to focus on massage

I just want to relax and be pampered

Have you had any facial injections or cosmetic procedures within the past 2 weeks?

Yes

No

Do you have any metal implants or a pacemaker?

Yes

No

Have you had any other professional facial treatments within the past month?

Yes

No

Have you had facial waxing within the past week?

Yes

No

Are you currently pregnant or breastfeeding?

Yes

No

Please list any known allergies or sensitivities:

Please list any current medications, especially those prescribed by a dermatologist, chemotherapy, or blood thinning medications:

Please select if you are affected by or have experienced any of the following:

Client Consent & Acknowledgment

I acknowledge that the skincare treatments and services provided by Ripple Skincare are for relaxation and cosmetic purposes only and are not a substitute for medical care. I confirm that all information I provided is accurate. I understand that results vary, and that certain treatments may cause temporary reactions.

By signing above, I give my voluntary consent to receive skincare treatments and release Ripple Skincare from any liability for any reactions due to undisclosed conditions.

Date of signature

Month

Day

Year