Client Intake/Consent Form
To learn a little more about you, your concerns, and the treatment(s) you'll be receiving! 

Must be 18+ or a guardians consent. 

(PSA: If you are receiving a chemical peel, or microneedling - stop using retinol or any exfoliators 3 days prior!) 
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Full Name  *
Date of birth  *
Phone Number
Email
What service(s) are you receiving today?  *
Required
What skin improvements would you like to see? 
Are you currently on any medications or breastfeeding? (Retinol, Accutane, Retina- A, Antibiotics, etc)  *
Health History (check all that apply) *
Required
Skin History (check all that apply) *
Required
Daily Skin Care (check all that apply)
Lifestyle (check all that apply)
Can I text you to remind you of future appointments, promotions, updates, etc? *
Service Consent (please sign and date):
I understand, have read and completed this form truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I understand the effects some of these treatments may have, as well as the treatment cancellation policy. The treatments I receive here are voluntary, and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 
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