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Client Intake Questionnaire

Please complete this form at least 2-3 days before your scheduled service appointment!

Medical History

Examples: Retin-A, Accutane (last yr), Antibiotics, Cigarettes, Stimulants, Diuretics, Oral Contraceptives
Laser, Botox, Fillers, etc.


Your Skin & Experiences

Skin Care Routine

For Example, Cleanse: Olay cleanser Tone: Seabreaze Exfoliate: Almond scrub.
If yes, please describe treatment and reaction.
By signing you agree that all information you have provided here is true and correct.
Office Use Only. Medical Director Signature