Client Intake FormPlease fill out this form before your appointment. Name * First Name Last Name Date MM DD YYYY Email * Medical Info List any allergies List any medications Family history of skin cancer? List any medical conditions I need to be aware of Are you currently using birth control? Do you smoke or vape? yes no How often do you exercise? Please share how much/duration/type of workout you do on a weekly basis. Skincare What products do you currently use on your skin? What are your biggest skincare concerns? In the middle of the day how does your skin feel? dry oily combo Are you using retinol? yes no Are you using any topical prescription skin creams? Have you had facial treatments in the past? If so, what? What are your goals for your treatment? Anything else you would like for me to know prior to treatment? Is there anyone that I can thank for your referral? Please type your name to serve as your electronic signature. Thank you! I am looking forward to seeing you at your scheduled appointment.-Betsy
