Client Intake Form Name * First Name Last Name Date of Birth MM DD YYYY Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country What are your skin goals and concerns? * What skin care products are you currently using? Have you ever had facials, chemical peels, microdermabrasion or any resurfacing treatments? Yes No Are you using Retin-A? Yes No Do you have any allergies or sensitivities? This includes; medicine, food/fruit, latex, shell-fish, certain cosmectic skin care/products. Please be thorough when lising below. How did you hear about us? Option 1 Option 2 Are you currently taking any medications? Accutane Birth Control Antibiotics Checkbox Option 1 Option 2 Thank you!
