Client Intake Form

Client Information

Full Name *

Date of Birth *

Age

Gender *

Female Male Other

E-mail *

Phone *

Address

City

Postal Code

How did you hear about us? *

Referral name (if applicable)

Medical Information & Skin History

Skin Concerns & Goals

What are your top skin concerns? (check all that apply)

Other concerns

What are your skin goals?

e.g. glowy skin, fewer breakouts, more hydration…

Current Skincare Routine

What products are you using regularly? (list brand or product type if known)

Cleanser

Moisturizer

Toner

Sunscreen

Essence / Serum

Exfoliants / Acids

How often do you exfoliate?

Daily 2–3x / week Rarely Never

Are you currently using any of the following?

Media Consent *

We love celebrating the results our clients achieve! Please let us know your preference below — selecting an option helps us respect your privacy and know how we can share your journey. Your care is never affected by your choice.

✨ Yes — photos & videos I'm happy for Aerlume to use before & after photos and short video clips of my treatment on social media, the website, and for portfolio use.

🙅 No thanks I prefer not to participate in media content at this time.

Your consent is always voluntary and can be withdrawn at any time by contacting us at info@aerlume.ca. We will never share content that identifies you without your explicit permission.

Consent & Signature

Thank you for providing accurate health and skincare information — it helps us tailor your treatment safely and effectively. All information and photos taken before and after your treatment will be kept confidential and will only be shared with your consent. Please note that we cannot be held responsible for any reactions due to incomplete or inaccurate details provided. By submitting this form, you confirm that you have read and understood this disclaimer and agree to proceed under these terms.

Date *

Client Signature *

Draw your signature above using your mouse or finger.