Client Skin Intake Form | Ritual Script Skincare
Ritual Script Skincare™ · Practice Form
Client Skin Intake Form
To be completed before your first appointment or consultation
Client Information
Full Name
Date of Birth
Phone
Email
Referred By
Skin Type — Select All That Apply
Dry
Oily
Combination
Normal
Sensitive
Reactive
Dehydrated
Acne-Prone
Primary Skin Concerns — Rank Top 3 (1 = Most Urgent)
Acne / Breakouts
Post-Acne Marks (PIH/PIE)
Fine Lines / Wrinkles
Uneven Skin Tone
Texture / Large Pores
Dryness / Flaking
Redness / Rosacea
Hyperpigmentation
Loss of Firmness
Barrier Damage
Sensitivity / Reactions
Other:
Medical & Prescription History — Select All That Apply
Currently using a prescription retinoid (tretinoin, tazarotene)
Currently using prescription topicals (antibiotics, azelaic acid)
Diagnosed skin condition (eczema, psoriasis, rosacea)
History of cold sores / herpes simplex
Currently pregnant or breastfeeding
Known allergies to skincare ingredients
List any known allergies or ingredient sensitivities
List current prescription skincare or relevant medications
Current Skincare Routine (Brief)
AM Routine (Key Products)
PM Routine (Key Products)
Actives Currently Using
SPF Used Daily?
Yes No Sometimes
Approx. Monthly Skincare Budget
Treatment Goals
What are you hoping to achieve from this consultation?
Have you worked with an esthetician or skincare coach before?
Yes No
How did you hear about us?
Ritual Script Skincare™ · ritualscript.com · Client Skin Intake Form · © Ritual Script Skincare · Evidence-based skincare education
This form is for intake and consultation purposes only and does not constitute medical advice, diagnosis, or treatment. For diagnosed skin conditions, please consult a licensed healthcare provider.