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Client Intake Form
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Name
*
First
Last
Phone Number
How Did You Hear About Us
Ethnicity
Caucasian
Asian
Hispanic
African American
CheckboxSkin Concerns (Check all that apply)
Acne
Hyperpigmentation
Redness
Sensitivity
Aging
Wrinkles
Texture
Scarring
Dullness Color
Firmness
Chest
décolleté
Blackheads
Pore size
Breakout
Congestion
that How ?
How would you describe your skin?
Do you smoke, drink or tan frequently?
Do you have any allergies (especially to skincare ingredients, latex, etc )?
Have you had facials, peels, laser, micro needling or injectable before?
Yes
No
Are you pregnant or breastfeeding ?
Do you have a tendency to keloid scar?
Yes
No
Do you suffer from claustrophobia or anxiety?
Do you take any medication?
Do you take any supplements?
What are your skin goals?
Are you currently using Retin A,AHA or any peeling agent?
What is your skin routine?(cleanser ,serum, moisturizer ,SPF etc.)
Signature
Clear Signature
Date
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