Effortless Beauty Clinic - Facial Intake Form
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Email *
What is your name? *
Phone Number *
Address, City, State, & Zip *
Emergency Contact & Emergency Contact's Phone Number? *
Date of Birth *
What are your main skin care concerns?   *
If you could wave a magic wand how would your skin look in one month?   *
Any special requests for today? (extractions, skin soothing, skin clearing, hydration, relaxation, waxing)   *
Is there anything I need to know before we get started? The more I know, the better your results. (Please List: allergies, sensitivities, pregnant, nursing, health issues, medications, metal plates, cold sores, herpes, Retin A use or any topic products that might cause skin sensitivity)   *
What did you LOVE about your last facial, and what could you have lived without?   *
Knowing that home care is a big part of achieving beautiful skin, would you like to chat about how to maintain today's results at the end of your facial?   *
Anything else you want to share? I love learning about my clients as it helps me provide superior customer service. *
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