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Returning Client Intake Form:
Please, fill out this one-time form at least 24 hours prior to your appointment. Be advised that your appointment may be rescheduled if any contraindications apply. Thank you for your preference, La Muse Skin.
Full Name
*
First Name
Last Name
If any personal info changed since your last visit, please fill it out below:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How would you describe your skin at the moment? Check all that apply
Dry
Combo
Oily
Normal
Sensitive
Are you experiencing any of these? Check all that apply
I experience a lot of breakouts
My Breakouts are painful
My nose looks like it has a lot of blackheads
I want to remove peach fuzz
I have discoloration
I have scarring leftover from acne
Products irritate my skin
My skin looks dull
My skin is often greasy
My skin turns red easily
I see fine lines on my skin
I want to lift/tighten my skin
Since Your last visit have you had any of the following:
Been under the care of a dermatologist since your last visit? If so, what for?
Started Accutane, Retin-A, or any other prescription skin care products? If so, what?
Received any injectables such as Botox etc. Since your last visit? If so, what treatment and when?
Received chemical peels, microdermabrasion, derma plane, or any other resurfacing treatments since your last visit? If so, what and when?
Developed allergies or sensitivities? If so, please specify.
Became pregnant, started lactating, or trying to become pregnant? Please, specify.
List any medications you take regularly
List any skin treatments you've been receive regularly (waxing, etc.)
List any new dietary restrictions
Do you smoke, consume alcohol/caffeine regularly? Please, specify.
Have you changed your makeup routine? or wear it less or more often?
Have you been wearing SPF since your last visit?
Have you tanned or had a sunburn since your last visit?
List all skincare products and brands you are currently using. (cleansers, exfoliants, toners, serums, moisturizers, oils, masks, SPF, tools, etc.) Please, be specific.
How often do you use your skincare? Check all that apply.
Morning
Middle of day
Night
Neither
Anything else that has changed since your last visit that you would like to share? (moods, medical info, travel, personal changes, stress triggers etc, )
Are there any treatments you'd like more info on? Check all that apply.
Dermaplaning
Chemical Peels
Microchanneling
Acne Bootcamp
Brazilian Waxing
Underarm Waxing
Back Facials
I give Nancy Brito of La Muse Skin LLC. permission to take photos and/or videos of me during my service for promotional/educational service. Also, to keep track of my progress.
*
I consent
I do not consent
If I experience any pain/discomfort during my treatment I will immediately make Nancy aware so that my treatment may be adjusted to my comfort. I further understand that aesthetic treatments should not be considered substitutes for medical examination, diagnosis, or treatments. Nothing in the course of my treatment should be constructed as a diagnosis, treatment, or prescription. Certain aesthetic treatments should not be performed under certain medical conditions or medications, therefore I affirm that I have stated all my medical conditions and medications. I agree to update Nancy Brito of La Muse Skin, LLC. of any change to my medical profile, and I understand that there shall be no liability on La Muse Skin, LLC. or Nancy Brito if I should fail to do so.
*
I agree
Signature
*
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