wix CLIENT INTAKE FORM | Illume Skin Therapy

ILLUME APPOINTMENT POLICY
AND INTAKE FORM

Confirmations are sent out 48hrs before your reserved time, please kindly inform us then if changes are required so your time may be given to another client.

Cancellations made less the 24hrs before appointment time will be charged 50% of service and failure to arrive for appointment will result in 100% of treatment cost charged.

Due to current covid virus, I understand and take full responsibility to reschedule my appointment if I am feeling unwell or have been exposed to anyone sick within the last 15 days.

I agree to the terms & conditions

Name

DOB

Your current skincare routine, as simple or complex as it may be (including product). This will help me understand your skin before we begin together and formulate a plan to achieve your best skin health!

What are your skincare goals/concerns?

Please tell me a bit of your skin history (including sensitivities, allergies, medications, injections, chemical peels, laser treatments, permanent cosmetics, tattoo, etc). Have you had recent injections?

Diet/digestion/gut microbiome health:

I feel good/balanced in this area

Imbalanced

This has been an issue in the past

Stress level:

Low

Medium

Struggling to manage current stress level

How do you manage stress (include modalities: breathwork, meditation, massage, acupuncture, walks in nature)

Please let me know if there is anything else you'd like to share as we begin your skincare journey.

As we continue to work together, I understand I must inform Illume Skin Therapy /
Holly Henton of any changes to my skin and health status before future appointments.

I look forward to working together,

Holly Henton

Illume Skin Therapy

ILLUME APPOINTMENT POLICY
AND INTAKE FORM

LOCATION

HOURS

CONTACT

ILLUME APPOINTMENT POLICY AND INTAKE FORM

LOCATION

HOURS

CONTACT

ILLUME APPOINTMENT POLICY
AND INTAKE FORM