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est. 2014
forms
Client Intake Form-Facial
First Name
Last Name
Email
Birthday
Have you ever had a facial?
No
Yes
What is your main concern with your skin?
Are you presently under a physician's care for any current skin condition or other problem?
If yes, please explain
Are you pregnant?
Answer here
Are you taking birth control pills?, If "Yes", what type?
Are you presently using (or used in the past) Azlex, Differin, Renova, Retin-A, Tazarac, Glycolic or AHA's?
Are you now using or have you ever used Accutane?
Are you presently taking any medications
Do you smoke?
Do you have any allergies to cosmetics, ingredients, foods or drugs?
Have you had skin cancer?
Do you often experience stress?
What skin care products do you use presently?
Upload File
Upload supported file (Max 15MB)
Please check if you are affected by or have any of the follwing:
Headaches-Chronic
Asthma
Depression
Herpes
Fever Blisters
Anxiety
Epilepsy
Hysterectomy
Skin Disease
Hepatitis
High Blood Pressure
Sinus Problems
Immune Disorders
Hair Loss
Eczema
Metal bones, pins or plates
Plastic Surgery
Botox
Please explain above problems or list any other significant issues.
Date
Initials
I confirm that the information given in this form is true
Submit
Thanks for submitting!
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