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Client Intake Form
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?
In the last month?
Do you use Retin-A, Renova, Adapalene Hydroxil Acid or Retinol / Vitamin-A derivative products?
Adapalene Hydroxil Acid
In the last 3 months?
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)
Sun spot/Liver spot/Brown spot
Uneven skin tone
What areas of concern do you have regarding your eyes? (Please check any that apply and explain)
What areas of concern do you have regarding your lips? (Please check any that apply and explain)
Have you ever had an allergic reaction to any of the following?
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?
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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