Intake, classic form
Cosmetic clinic intake template
A pre consultation form with treatments of interest, skin type, skin conditions, previous treatments, health history, upcoming events and a photo.
17 questions, 14 required, as a classic form
Use this template opens a copy in the form builder after you sign in. Adapt it with AI opens the generator with this template chosen, so you can describe your business and get the questions rewritten for it.
Every question
Your name (required)
Full name
Date of birth (required)
Date
Mobile (required)
Short answer
Email (required)
Short answer
Which treatments are you asking about? (required)
Multiple choice: Wrinkle relaxing injections, Dermal filler, Skin needling, Chemical peel, Laser or IPL for pigment, Laser for redness or veins, Laser hair reduction, Skin tightening, Medical grade skincare only, Not sure, I want advice
What would you like to be different, in your own words? (required)
Long answer
How does your skin behave in the sun? (required)
Single choice: Always burns, never tans, Burns easily, tans a little, Sometimes burns, tans gradually, Rarely burns, tans easily, Very rarely burns, tans deeply, Never burns, deeply pigmented
Do any of these apply to your skin? (required)
Multiple choice: Acne, active now, Rosacea or easy flushing, Melasma or patchy pigmentation, Eczema or dermatitis, Psoriasis, Keloid or thick raised scars, Cold sores that recur, Very sensitive or reactive skin, Recent sunburn or a tan, None of these
Previous cosmetic treatments
Table
Are you pregnant, breastfeeding or trying to conceive? (required)
Single choice: No, none of these, Pregnant, Breastfeeding, Trying to conceive, Prefer to discuss at the consultation
Medications and supplements, with doses
Long answer
Health conditions and history (required)
Multiple choice: An autoimmune condition, Diabetes, A bleeding disorder or blood thinning medication, A neurological condition affecting the face or muscles, Immune system suppressed by medication or illness, Cancer treatment in the last two years, Isotretinoin in the last twelve months, A permanent implant, thread or facial surgery, A known allergy to a local anaesthetic, None of these
Is there an event you are planning around? (required)
Single choice: No, nothing in particular, Something within the next two weeks, Something in two to six weeks, Something two to six months away, A wedding, and I am in it
Sun, tanning and travel in the next four weeks (required)
Single choice: Nothing planned, normal daily sun only, A beach or snow holiday booked, Regular outdoor sport or work, Planning to use fake tan or a solarium
A photo of the area you want to discuss
Photo
Before you sign (required)
Multiple choice: I understand this form books nothing and that suitability is decided at the consultation
Signature (required)
Signature
What you fill in
- [Your company]