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Aesthetician Client Intake Form Template

A printable client intake form for aestheticians and skin clinics. It covers the screening questions that decide whether a peel, microneedling, or laser treatment is safe today, plus the consent and communication preferences Canadian clinics need to record.

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Last reviewed September 2026 · Not legal advice

The questions that change the treatment

Most of an intake form is administration. A handful of questions actually decide what you can do safely. The first is retinoid use and when it was last applied, because most peel and microneedling protocols pause retinoids for several days beforehand. The next is isotretinoin (Accutane) in the past six to twelve months. Then a history of cold sores, which can flare after resurfacing treatments. Then recent sun exposure or tanning, and pregnancy.

Fitzpatrick skin type belongs on the form too, but treat the client's answer as a starting point and confirm it yourself. It is the input that most often changes settings and depths, and it is where post-inflammatory hyperpigmentation risk comes from.

Consent and communication in Canada

Record treatment consent, photo consent, and your cancellation or deposit policy as separate acknowledgements. They answer different questions if a dispute ever comes up.

Marketing emails and texts need express opt-in under Canada's Anti-Spam Legislation (CASL). A pre-ticked box doesn't count. Appointment reminders are transactional and usually fall outside that rule, but newsletters and promotions don't. Keep the opt-in as its own unticked checkbox.

Clinic name · address · phone

Client Intake and Skin History

Contact details

Full name

Date of birth

Phone

Emergency contact (name and phone)

Skin goals

What would you like to work on?

Acne or breakouts
Acne scarring
Pigmentation or sun spots
Fine lines and wrinkles
Redness or rosacea
Texture or pores
Dryness or dehydration
Hair removal

Anything else we should know about your goals?

Skin history

How does your skin respond to sun?

Always burns, never tans
Burns easily, tans minimally
Sometimes burns, tans gradually
Rarely burns, tans well
Very rarely burns, tans deeply
Never burns

Do you use a retinoid or retinol (e.g. tretinoin, adapalene, retinol serum)? If yes, when did you last apply it? Yes NoIf yes, details

Have you taken isotretinoin (Accutane) in the past 12 months? Yes NoIf yes, details

Do you get cold sores (herpes simplex)? Yes No

Have you had sun exposure, tanning, or self-tanner in the past two weeks? Yes No

Have you had waxing, laser, peels, injectables, or other skin treatments in the past month? Yes NoIf yes, details

Do you scar easily or form raised (keloid) scars? Yes No

Health

Are you pregnant, trying to conceive, or breastfeeding? Yes No

Are you taking any medications, including antibiotics, blood thinners, or supplements? Yes NoIf yes, details

Do you have any allergies (e.g. latex, aspirin or salicylates, lidocaine, fragrance)? Yes NoIf yes, details

Do you have any of the following?

Diabetes
Autoimmune condition
Epilepsy or seizures
Pacemaker or metal implants
Active skin infection
Eczema or psoriasis
Bleeding disorder
None of these

Policies and consent

InitialsThe information I have provided is accurate and complete. I will tell the clinic if my health, medications, or skincare routine changes.

InitialsI have read and agree to the clinic's cancellation and deposit policy.

Communication preferences:

Appointment reminders by text
Appointment reminders by email
I'd like to receive offers and news by email (optional)

Signatures

Client / patient signature

Date

Practitioner name and signature

Date

Template from zdrovia.ca/templates/aesthetician-client-intake-form/ · Review with your medical director, regulatory college guidance, and insurer before use.

Send this form before the appointment instead of printing it

Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.

Start free, no card required See how digital forms work →

See how Zdrovia is set up for aestheticians.

Frequently asked questions

What should be on an esthetician intake form?

Contact and emergency details, skin goals, skin history (Fitzpatrick type, retinoid and isotretinoin use, cold sores, recent sun exposure and treatments), health screening (pregnancy, medications, allergies, relevant conditions), policy acknowledgements, communication preferences, and a signature.

How often should clients update their intake form?

Ask returning clients to confirm or update their history before any treatment where it matters, such as peels, microneedling, and laser, and at least once a year. Medications and skincare routines change more often than people think to mention.

Is it aesthetician or esthetician?

Both spellings are used in Canada. Esthetician is common in provincial college programs and job titles, while aesthetician is often used for medical aesthetics roles. The form works for either.

This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.