NEW CLIENT FORM

NEW CLIENT FORM

Fill out this quick questionnaire and one of our Licensed Estheticians/Laser Technicians will get back to you as soon as possible with the perfect first treatment FOR YOU!
Name

First NameLast Name
Best number to text you your results at:

Area CodePhone Number
What are your biggest skin concerns?

Fine lines & wrinklesAcneAcne scarringPigmentation (melasma, red scarring, sun damage, etc.)PoresBlackheadsTextureUneven Skin ToneDull skinJust want healthier/more glowy skinOther
Are you ok with a treatment that may have “down time” that may help you reach your skin goals? (Ex: redness, flaking, peeling, etc.)

YesNo
What products are you currently using on your skin?
Anything else you’d like us to know about your skin?
Briefly describe any medications you may be on or health conditions you may have:
Are you pregnant or breastfeeding?

YesNo
We will send you a message as soon as possible with our first treatment recommendation for your skin!

Thank you for choosing Revive Skin Bar! We can't wait to help you with your skin!
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