Esthetician Facial Intake
A facial / esthetician intake — client and prior history, current skin concerns, products in use, sensitivities and contraindications, scope-of-practice acknowledgment, and consent for the treatment plan.
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Linden Skin Studio
ESTHETICIAN FACIAL INTAKE
Licensed Esthetician: Avery Park, LE License #: IL-LE-22188
CLIENT
Name: Riley Tran DOB: April 8, 1992
Phone: +1 217 555 0199 Email: riley.tran@example.com
CONCERNS & GOALS
Combination skin — T-zone congestion, occasional jawline breakouts (cyclical). Some sun damage / hyperpigmentation on cheeks. Goal: clearer pores and even tone over a course of 4–6 facials.
SKIN TYPE
Fitzpatrick: III — sometimes burns, gradually tans
CURRENT PRODUCT REGIMEN
AM: gentle gel cleanser, vitamin C serum, SPF 50.
PM: gentle cleanser, niacinamide serum, retinol 0.3% (3×/week — stopped 5 days ago for this facial).
No prescription tretinoin. No hydroquinone currently.
(Retinoids, AHAs/BHAs, and benzoyl peroxide thin the stratum corneum
and can trigger irritation during a facial. Pause retinoid 5–7 days
before exfoliation/extractions; pause prescription tretinoin 7–14 days
and have the client confirm with the prescriber.)
ISOTRETINOIN
No
(Isotretinoin/Accutane currently or within the past 6 months
contraindicates exfoliation, extractions, and chemical peels due to
skin fragility. Defer until cleared by the prescriber.)
ALLERGIES & SENSITIVITIES
No known topical allergies. Mild fragrance sensitivity — request fragrance-free products where possible.
MEDICAL / PREGNANCY / RECENT PROCEDURES
No active cold sore (would defer treatment if present). No recent botox/filler within 14 days. Not pregnant. No autoimmune skin condition active. No recent sun exposure to face within 48 hours.
PLANNED SERVICES TODAY
Double cleanse · gentle enzyme exfoliation · light steam · manual extractions (T-zone only) · soothing mask · brief LED red-light · daily-use moisturizer + SPF 30 reapplied to skin before client leaves.
SCOPE-OF-PRACTICE ACKNOWLEDGMENT
Yes
The esthetician scope of practice is defined by the state licensing
board and typically includes: cleanse, exfoliate (mechanical and
enzyme/light chemical), extract, mask, light therapies (LED, high
frequency), light peels within state-defined depth limits, and skincare
product recommendation. OUT OF SCOPE in most states: deeper chemical
peels, microneedling and RF microneedling, laser, prescription products
(tretinoin, hydroquinone above OTC strength, antibiotics), Botox/filler.
For out-of-scope concerns the client is referred to a dermatologist or
licensed medical aesthetic provider.
CONSENT
I confirm the information above is accurate to the best of my knowledge.
I understand the planned services and the esthetician's scope of
practice, and I consent to the services above. I will tell the
esthetician about any discomfort or reaction during the service.
SIGNATURES
Client: ____________________________ Date: ____________
Riley Tran
Esthetician: ____________________________ Date: ____________
Avery Park, LE
(Retain this intake in the client file. Update at each visit if
products, conditions, or medications have changed since the prior facial.)
About this template
An **esthetician facial intake** is two things at once: a **skin-history conversation** that lets the esthetician design the treatment, and a **scope-of-practice acknowledgment** that defines what the esthetician will and will not do. The intake asks about **current skin concerns and goals** (acne, congestion, hyperpigmentation, dryness, sensitivity), **Fitzpatrick skin type** (which affects exfoliation depth, light/laser settings if used, and post-inflammatory hyperpigmentation risk), the **current product regimen** with specific attention to **retinoids, AHAs/BHAs, benzoyl peroxide, and prescription tretinoin** (all thin the stratum corneum and can trigger irritation during a facial — pause 5–14 days depending on potency), **isotretinoin / Accutane** use (a hard contraindication for exfoliation, extractions, and peels currently and within the past 6 months due to skin fragility), **allergies**, and **medical conditions and recent procedures** (Botox/filler within 14 days, active cold sore, recent sun exposure, pregnancy considerations for certain ingredients). The **planned services** section sets expectations for the appointment — a typical sequence: double cleanse, exfoliation (mechanical, enzyme, or light chemical), steam, manual extractions, mask, light therapy (LED, high-frequency), moisturizer and **SPF reapplied before the client leaves**. The **scope-of-practice acknowledgment** is the most legally important section: state licensing boards (e.g., the Illinois Department of Financial and Professional Regulation, the New York Department of State, the California Board of Barbering and Cosmetology) define what an esthetician may perform — typically **cleanse, exfoliate, extract, mask, LED, light peels within state-defined depth limits**, and skincare product recommendation. **Out-of-scope** services in most states include **deeper chemical peels, microneedling and RF microneedling, laser, prescription products (tretinoin, hydroquinone above OTC strength), Botox/filler** — those require a licensed medical aesthetic provider. Make the boundary explicit on the form and refer out for out-of-scope concerns; the referral is the safest legal posture and best for the client.
When to use it
- New-client first facial intake.
- Returning-client update when products, conditions, or medications have changed.
- Pre-service review when adding a new modality (LED, light peel) to a returning client.
- Scope-of-practice clarification when a client requests a service the esthetician cannot perform.
What to include
- Client identity and contact.
- Skin concerns and goals.
- Fitzpatrick skin type.
- Current product regimen (retinoids, AHAs/BHAs flagged).
- Isotretinoin / Accutane history.
- Allergies and contraindications.
- Planned services + scope-of-practice acknowledgment.
- Signatures.