New Client Form | CCC Wellness

Client Information

First Name

Last Name

Birthday

Month

Day

Year

Phone

Email

Address

Emergency Contact

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Relationship

Emergency Contact Phone

Medical History

Use this space to provide details for any checked conditions above that need more explanation, or to note any conditions not listed (e.g., type, severity, treatment, or current status)

Skin & Lifestyle History

What’s your skin type? (No stress if you’re not sure — we’ll discover it together!)

Normal – Balanced oil and moisture, few blemishes, even tone.

Oily – Excess oil, shiny appearance, enlarged pores, prone to breakouts.

Dry – Lacks oil, feels tight or rough, may have flaking.

Combination – Oily in some areas (usually T-zone: forehead, nose, chin) and dry/normal in others.

Sensitive – Easily irritated, prone to redness, burning, or stinging.

Mature/Aging – Reduced elasticity, fine lines, wrinkles, or age spots.

Dehydrated (can occur with any skin type) – Lacks water, feels tight, dull, may show fine lines.

What are your current skincare concerns? (Check all that apply)

Breakouts & Congestion (acne, blackheads, clogged pores, hormonal breakouts)

Tone & Pigmentation (uneven tone, dullness, dark spots, sun damage, redness)

Hydration & Oil Balance (dryness, dehydration, oily skin)

Aging & Firmness (fine lines, wrinkles, loss of elasticity)

Texture & Sensitivity (rough texture, large pores, sensitivity, eczema/psoriasis)

Are you currently taking any medications? (Please specify below)

Which treatment did you last receive?

Date of last treatment (if any)

Month

Day

Year

Other allergies or sensitivities (please specify):

Current Skincare Routine

List any skincare products you currently use at home (e.g., cleanser, moisturizer, SPF, serums, masks, etc.):

Consent & Policies

Consent to Treat – I consent to receive facial and/or skincare treatments from CCC Wellness. I understand that results may vary and agree to follow all recommended post-care instructions.

Release of Liability – I acknowledge that CCC Wellness and its staff are not responsible for any adverse reactions resulting from undisclosed medical conditions, allergies, or medications.

Cancellation Policy – I understand that appointments canceled with less than 24 hours’ notice may be subject to a cancellation fee.

I have read, understand, and agree to the policies above.

Client Signature

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Date of Signature

ID Upload

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