Client Intake Form Short

First name

Last name

Email

What brings you to this service?

Do you have any medical conditions I should be aware of?

(diabetes, thyroid disorders, autoimmune conditions, heart conditions, epilepsy etc.)

Do you have any allergies or sensitivities?

(skinare, medications, ingredients, food etc.)

Are you taking Accutane (roacutan) or using any topical retinoids such as tretinoin (retin-a), adapalene, or retinol?

(please specify frequency of use and how long you have been using it)

Are you pregnant or breastfeeding?

I give my consent for the facial treatment and acknowledge I have shared all relevant health information.

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