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Earth & Essence: First Time Client Consultation/Consent Form
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First and last name *
Phone number *
Email *
Birthday *
MM
/
DD
/
YYYY
Do you have any allergies or sensitivities? *
Have you had any laser/chemical peels/botox/microneedles in the last month? *
If yes, please explain
Are you on any medications? *
If yes, please explain
Check any health conditions that may apply *
Required
Do you have or have experienced any of the following? *
Required
Any other relevant health information?
What would you consider your skin type? *
Required
Do you have any skincare goals for your session?
What skincare are you currently using?
Stress Level *
1
2
Is there anywhere you are not okay with being massaged?
What are your goals for your appointment? *
Required
Would you like a silent appointment? *
Is there anything else you would like me to know or special requests?
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