CLIENT INTAKE FORM - Elise de Clair Aesthetics

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312-810-2626
admin@elisedeclairaesthetics.com
Orland Park IL, 60462

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Book Appointment

Client Intake Form

Please fill up the form below to proceed.

To provide you with the safest and most personalized treatment experience, we kindly ask you to complete our client intake form before your consultation or appointment. FIll out the form below and we will book you as soon as possible!

Patient Intake Form

First Name

Middle Name

Last Name

Age

Date of Birth

Gender

Status

Phone no.

Email

Address

City

State

Country

Occupation

How did you hear about us?

Emergency Contact Person

Emergency Contact Number

Do you currently have or have you had any of the following? (Check box if you have)

Diabetes

High Blood Pressure

Heart Condition

Autoimmune Disease

Skin Disorders (Eczema, Psoriasis, Rosacea, etc.)

Keloid Scarring Tendency

Cancer (Past or Current)

Thyroid Problems

Hormonal Imbalance

None

Other

If yes, please specify:

Do you have any allergies?

Yes

No

If yes, please specify:

Are you currently taking any medication or supplements?

Yes

No

If yes, please specify:

Skin Type:

Oily

Dry

Combination

Sensitive

Acne-prone

Current Skin Concerns:

Acne

Pigmentation

Wrinkles / Fine lines

Dull skin

Larg pores

Scarring

Redness

Other

Please specifiy other skin concerns:

Current Skin Concerns:

Facial Treatments

Laser Procedures

Botox / Fillers

Chemical Peel

Microneedling

Thread Lift

Surgery

None

Date of last treatment:

Do you smoke?

Yes

No

How long have you been smoking?

Alcohol Consumption

None

Occassionally

Regularly

Sun Exposure

Minimal

Moderate

High

What are your main aesthetic goal?

Privacy Policy & Data Protection

I consent to the collection, use, and storage of my personal and medical information for consultation, treatment, and clinic-related communication purposes.

Treatment Consent

I confirm that the information provided is accurate and complete. I understand that withholding medical information may affect treatment safety.

Treat yourself

Experience thoughtful aesthetic care designed for subtle, lasting confidence.

Begin Your Experience! Whether you're seeking glowing skin, fuller hair, or refined facial balance, we curate a treatment plan uniquely yours.

Book Appointment Now

Privacy Policy | Data Consent

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Email: admin@elisedeclairaesthetics.com
Contact Number: 312-810-2626
Address: Orland Park IL, 60462

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