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Client Intake Form
NAME
EMAIL
PHONE
BIRTHDAY
LIST ALL ALLERGIES
LIST ALL COSMETIC PROCEDURES IN THE LAST 12 MONTHS
BRIEFLY EXPLAIN YOUR CURRENT SKIN CARE REGIMEN
DO YOU WEAR SPF DAILY?
Yes
No
WHAT ARE YOUR BIGGEST SKIN CONCERNS?
PLEASE SELECT ALL THAT APPLY
I am pregnant
I am a smoker
I use tanning beds
I am diabetic
I have a history of cold sores
I am epileptic
I am undergoing hormone therapy
I have been treated for cancer/skin cancer
I am prone to keloids
I have used retinol, AHA, or BHA in the last 72 hours
SUBMIT
*If you receive an error message after submitting, just know that we DID receive the intake form. Some web browsers block the confirmation page.
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