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CLIENT INTAKE FORM

Name*

Address*

Email Address*

Phone Number*

Date of Birth

Occupation:

Areas of Concern:*

Allergies*

Are you currently using any Retinols or Retin A products

Are you currently under the supervision of a doctor?*

If Yes, for what?

Have you been Diagnosed with Cancer?*

If Yes, what type and what treatments were used?

Have you had any injectables?

If yes, where and when was the last time?

Are you currently pregnant?

If Yes, Due Date?

Services Requested:

Are you using a tanning bed?

If Yes, how often?

Are you taking medication?

If yes, What?

What days and times work best with your schedule?

Message*

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