About this template
A skin care consultation request form is an essential tool for dermatologists, estheticians, and skin care specialists looking to understand new clients' needs before beginning any treatment. Gathering detailed background information in advance ensures safe treatments and personalized service recommendations.
This comprehensive intake form collects vital client details including contact information, medical history, known allergies, prior cosmetic treatments, and specific skin care goals. By moving this process online, practitioners can review client history ahead of time, streamline appointments, and maintain organized digital records.
Doc2Form makes it easy to deploy this consultation template as a Google Form in seconds. Clients can conveniently fill out the questionnaire from their smartphone, tablet, or computer before arriving for their appointment, saving valuable time during their in-person visit.
Key features
- Collect detailed skin history and allergy alerts upfront
- Understand client goals and target areas before treatment
- Seamlessly accessible on mobile devices and computers
- Organize responses automatically in Google Sheets
- Fully customizable to fit your specific practice or clinic
Use cases
- New patient onboarding at a dermatology clinic
- Pre-treatment intake for professional estheticians and spa staff
- Virtual skin care consultations and telemedicine assessments
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Birth Date (Date)Please provide your date of birth.
- Email Address (Short answer)Where can we send your appointment confirmations and follow-up care instructions?
- Phone Number (Short answer)Enter your preferred contact number.
- Home Address (Paragraph)Enter your current mailing address.
- How did you hear about us? (Dropdown)Select the primary source that referred you to our practice.
- Referred By Name (Short answer)If someone specific referred you, please enter their name here.
- Do you have any known allergies? (Multiple choice)Include any known reactions to skincare ingredients, latex, or medications.
- List Your Allergies (Paragraph)If you answered yes above, please list all relevant allergies and sensitivities.
- Have you had professional facial treatments or peels before? (Multiple choice)Let us know your level of experience with professional skin care services.
- Date of Last Professional Treatment (Short answer)If applicable, approximate when you received your last facial or skin treatment.
- Are you currently under the care of a dermatologist? (Multiple choice)Let us know if you are managing any active medical skin conditions.
- Dermatologist Care Details (Paragraph)If yes, please describe the condition being treated and any prescription medications you are using.
- Do you have permanent cosmetics or tattoos on your face? (Multiple choice)This helps us avoid treating sensitive areas with certain devices.
- Permanent Cosmetic or Tattoo Areas (Short answer)If yes, please specify where on your face or neck.
- Do you experience hyperpigmentation after trauma or injury? (Multiple choice)E.g., dark spots left behind after acne or cuts.
- What are your primary skin improvement targets? (Checkboxes)Select all concerns you would like to address.
- What are your overall skin care goals? (Paragraph)Describe what you hope to achieve through our treatments and home care routine.
- Current Skin Care Products (Paragraph)List the cleanser, moisturizer, SPF, and active products (like retinols or acids) you currently use.
- Terms and Conditions Acceptance (Multiple choice)I confirm that the information provided above is accurate and complete to the best of my knowledge.
- Signing Date (Date)Enter today's date.
- Client Signature (Short answer)Please type your full legal name as an electronic signature.
FAQ
How do I share this form with my clients?
Once your template is generated as a Google Form, simply copy the shareable link and send it via email, text message, or post it directly on your booking page.
Can I add or remove questions from this template?
Yes! Since the form is built directly in Google Forms, you have full control to edit, add, or rearrange any questions to suit your specific treatments.
Where are the form responses stored?
All client submissions are automatically saved in a linked Google Sheet, allowing you to review patient details and export data securely.
Is this form mobile-friendly for my clients?
Google Forms are fully responsive, meaning clients can easily complete their consultation request on their smartphones, tablets, or desktop computers.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.