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Anchor 1
Client Intake Form
Gender:
Have you ever had facial treatment before?
Do you have any special skin problems or concerns pertaining to your face or body?
Have you ever had chemical peels, laser or microdermabrasion?
Chemical Peels
Microdermabrasion
Laser
In the last month?
Do you use Retin-A, Renova, Adapalene Hydroxil Acid or Retinol / Vitamin-A derivative products?
Retin-A
Adapalene Hydroxil Acid
In the last 3 months?
Renova
Retinol / Vitamin-A
Have you ever used any acne medication?
Have you recently used any self-tanning lotions, creams or treatments?
What areas of concern do you have regarding your skin? (Please check any that apply and explain)
Breakouts/Acne
Blackheads/Whiteheads
Excessive oil/Shine
Rosacea
Broken capillaries
Redness/Ruddiness
Sun spot/Liver spot/Brown spot
Uneven skin tone
Sun damage
Wrinkles/Fine lines
Dull/Dry skin
Flaky skin
Dehydrated
Other
What areas of concern do you have regarding your eyes? (Please check any that apply and explain)
Dehydrated
Puffiness
Wrinkles
Dark circles
Other
What areas of concern do you have regarding your lips? (Please check any that apply and explain)
Dehydrated
Cracked/Chapped lips
Other
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Suncreens
Iodine
AHAs
Fragrance
Shellfish
Latex
Drugs
Other
Pollen
Are you taking any oral contraceptive?
Any recent changes to or from your contraceptive treatment?
Are you pregnant or trying to get pregnant?
Any menopause problems?
Are you undergoing any hormone replacement therapy?
What is your current shaving system?
Do you experience irritation form shaving?
Ingrown hairs?
May we call you on your cellphone to confirm future appointments?
May we contact you via email about future promotions and news?
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I accept the terms & conditions
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