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Welcome to Cantik Esthetics Skin Care-Intake Form

This intake form is the first step in your professional skin assessment. It allows a detailed understanding of your skin concerns, history, and treatment goals so your consultation and treatment plan can be precisely tailored to you.

By completing this form in advance, we are able to apply a structured “skin detective” approach — ensuring your appointment time is focused on evaluation, treatment, and results rather than administrative review. This supports safer, more efficient, and more effective outcomes.

Every treatment is individualized, results-driven, and guided by clinical esthetic assessment to ensure your skin receives the attention it needs from the very beginning.

Facial Sculpting Surrey, BC

New Client Intake Form

This intake form helps us understand your skin concerns and determine the most appropriate treatment prior to your appointment at Cantik Esthetics Skin Care

Treatment Goals & Expectations

Please describe what you would like to improve and your desired outcome from treatment.

Primary Skin Concern

Area of Concern


Medical Disclosure

Skin Irregularities | Thermocoagulation-Are you currently taking any anticoagulant (blood-thinning) medications?

If yes, please list the medication(s):

Are you using prescription skincare or active ingredients (retinol, acids, etc.)?

Treatment History

Have you received professional esthetic treatments before?

  • If yes, please specify type(s)

  • Any past reactions or complications?

Treatment Readiness


Client Agreement & Policy Acknowledgment

I confirm I have read and agree to the Clinic Policies & Expectations

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Information provided is used to support safe and appropriate treatment planning.

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