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Client Intake Form

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Welcome to Kyleigh Wolfgang Aesthetics

Dedicated to providing you with a tailored and serene skincare experience. Please take a moment to fill out the following form with as much detail as possible. This information will help customize your treatments and ensure the highest standard of care and safety.

Complete each section carefully, and don't hesitate to include any additional notes that might assist in better understanding your unique needs. Thank you for taking the time to share this important information.

Your Privacy is Top Priority

Please be assured that all personal and medical information provided here is strictly confidential and will be used solely to customize your skincare treatments to your unique needs. Your privacy and trust are of utmost importance.

Client Information

Name
Date of Birth
How did you hear about Kyleigh Wolfgang Aesthetics?
What music would you prefer to listen to?

Medical Information

Please indicate any medical conditions:
Have you been under a dermatologist's care within the past year?
Have you had an allergic reaction to any of the following?

Esthetics Information

Have you had a facial before?
What areas of concern do you have regarding your skin?
Within the past 3 months, have you used Retin-A, Renova, AHAs or Retinol (Vitamin A-derivative products)?
Have you received Botox, Restylane, or Collagen injections in the last 6 months?
By signing this form, I hereby affirm that the information provided in this form is accurate and complete to the best of my knowledge and understand that it is my responsibility to inform the esthetician of any changes in my medical history. I acknowledge having been apprised of the contraindications for the proposed treatment procedures and assert that I have no known condition that contraindicates such treatments. Should I experience any discomfort during my treatment, I shall immediately inform the esthetician to allow for appropriate adjustments. By signing this form, I agree to release the esthetician and their associated business from any and all liability for injuries or damages I may sustain as a result of my failure to disclose such information.
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