top of page

Client Intake Form



Please check all that apply


Are you currently taking any medications?
Do you have any allergies?
Do you smoke or consume alcohol?


Please describe your skin type:
Have you had any facial or dermatology services in the past 30 days?
Have you used any Bleaching, Retin-A, AHAs or Retinol/Vitamin A products in the last 90 days?
Have you had any Botox, Restylane, Juvederm or Collagen injections within the last 6 months?
Any history of Accutane (isotretinoin) use?
Do you frequently use tanning beds or have had any excessive sun/UV exposure within the last 4 weeks?

Please check all that apply


Would you like to be added to our email list for specials and discounts?

If you cancel within less than 24 hours you will be charged the full fee, unless it is a viable emergency situation kind of thing. Your signature on this form shows you have seen and consent to this policy. 


I understand that this form and it's data are completely confidential. The information I have provided regarding my medical history is accurate to the best of my knowledge, and I affirm I do not have any ailments or conditions that would make this treatment/procedure incompatible with my health and wellbeing. By signing this form, I certify that I am at least 18 years of age and fully competent to give my consent; that I have been given the opportunity to ask any questions I may have, and those questions have been answered. I acknowledge the information given to me pertaining to the requested treatment(s)/procedure(s), and I have been sufficiently informed of the benefits and risks involved. I agree to inform my Esthetician/Technician if I experience any pain, discomfort, or sensitivities during treatment, allowing for them to make the appropriate adjustments. I agree to waive all liability towards my Esthetician/Technician and Wild Heart Aesthetics, for any possible harm or injury in the case of my failure to disclose any and all/past and present health conditions.

Thanks for submitting!
We’ll keep your info confidential.

bottom of page