• Client Intake Form

    Please fill out
  • Gender
  • Date of Birth
     - -
  • Format: (000) 000-0000.
  • Have you been in contact with anyone diagnosed with COVID-19 in the past 14 days?*
  • Do you have any of the following conditions? If yes, please select them:*
  • Skin condition*
  • Fitzpatrick Skin Type (check our Instagram if you aren’t sure)*
  • What areas of concern do you have regarding your skin?*
  • Do you consume alcohol?*
  • Do you smoke?*
  • Are you pregnant?*
  • Are you trying or planning to be pregnant?
  • Are you taking any contraceptive pills?*
  • Are you breastfeeding?
  • Do you consume caffeinated drinks?*
  • Are you wearing any contact lenses?
  • Are you currently under any kind of diet?
  • Have you undergo any surgeries?*
  • Do you have any metal implants?*
  • Do you use SPF daily?
  • What beauty or cosmetic products you’re currently using?
  • Have you received Botox, Restylane or Collagen injections in the last 6 months?*
  • Do you use Retinol, Retinoid, or Retin-A?*
  • Have you ever had any chemical peels, microdermabrasion, or any resurfacing treatments?*
  • Within the last 12 months, have you been under a dermatologist or other physician’s care?*

  • Terms & Conditions

  • I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. 

    I confirm that all information in this form is true and accurate.

    I confirm that if I hold some important information and complications happened, the clinic will not be liable.

    I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.

  • Date Signed
     - -
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  • Should be Empty: