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Consultation Form
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Facial Intake Form:
First name
*
Last name
*
Birthday
*
Email
*
Phone Number
*
Address
*
Emergency Contact (Name & Number)
*
Todays Date
*
Are you pregnant?
*
Yes
No
Do you have any of the following health conditions?
*
AIDS/HIV
Cancer
Diabetes
Heart Problems
Hepatitis
High/Low Blood Pressure
Lupus
Recent Surgeries
Strokes
None
Other
Are you using any of the following?
*
Retinol
Glycolic Acid
Accutane
Topical Vitamin C
Hydroquinone
Hormone Replacement Therapy
Birth Control
None
Other
If yes, please list names of any prescription medication(s):
Are you using or have ever used any medications for acne?
*
Yes
No
If yes, how long has it been since you last used acne medication?
Do you suffer from cold sores?
*
Yes
No
If yes, do you use medication?
Yes
No
Do you smoke?
*
Yes
No
Do you tan?
*
Yes
No
Have you received facials before?
*
Yes
No
Have you had electrolysis, laser hair removal, or waxing in the last week?
*
Yes
No
What skin care products are you currently using? (List brand where known)
*
What areas of concern do you have regarding your skin:
*
Signature
*
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Parental Signature (if client is a minor)
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Submit
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