DERMAPLANE CLIENT MEDICAL INTAKE FORM
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First Name *
Last Name *
Address as shown on ID *
Mobile: *
Emergency Contact
Full Name *
Mobile *
Primary Physician / GP
Do we have permission to show contact by phone or leave messages? *
Do we have permission to show your photos for portfolio purposes on social media? *
What concern you most about the overall appearance of your skin? (check all that apply) *
Required
How would you describe your skin? *
Required
How would you describe your stress level? *
Do you feel your stress level may be affecting the health of your skin? *
Are you in good health overall? *
HISTORY
Are you currently under the care of Physician? YES or NO. If YES, please explain: *
Do you have any allergies to foods, cosmetics or medications? YES or NO. If YES, please expalin: *
Are you currently on medications (regular or temporary), either topical or oral? YES or NO. If YES, please explain: *
Ethnic Background (Parents, Grandparents & Great Grandparents): *
How do you heal after an acne breakouts, cut or scratch? *
Required
Do you smoke? *
Are you prone to cold sores? YES or NO. If YES, date of last cold sore? *
Do you have an allergy to Latex? *
Do you tan in the sun or in tanning beds/booths? *
Please check the skincare products you are currently use *
Required
Anything else we should know?
The answers I have provided are true and correct to the best of my knowledge.
Agreed *
Required
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