Client Intake Form
To ensure that you receive your full appointment time, ensure that you fill out applicable forms prior to arriving at ETS. Please set aside 10-15 minutes to complete the required paperwork. All appointments need to complete both Client Intake Form + Photography Release forms. I look forward to working with you! - Zenani
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Email
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example@example.com
Date of Birth
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
How did you find out about my services? If you were referred, please list their name.
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Occupation
Does your job involve working outdoors?
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Yes
No
What would you like to achieve from your treatment today?
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Have you ever has an allergic reaction to any of the following? Please check any that apply.
Cosmetics
Medicine
Food (papaya, pineapple, nuts etc.)
Animals
Sunscreens
Alpha Hydroxy Acids
Fragrance
Shellfish
Latex
Aspirin
Sulfur
Other
Explain any allergies:
Are you pregnant or nursing?
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Yes
No
Have you ever had a facial treatment before?
Have you had any kind of cosmetic injections in the last month? If yes, when (date)
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Do you have any special skin problems or concerns pertaining to your face or body? If so, please specify.
Which of the following best describes your skin type?
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Fair Complexion- always burns easily and never tans
Light Complexion- always burns and tans slightly
Light/Med Complexion-burns moderately and tans gradually
Medium Complexion- seldom burns and always tans well
Brown Complexion- rarely burns and deep tan
Deep Complexion- never burns deeply pigmented
Other
Do you use Retin-A, Retinol/Vitamin A derivative products? If yes, please describe:
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Have you used any of these Retinol/Vitamin A products in the last 3 months?
Yes
No
Approximate date of last use:
Do you use an acne medication? If yes, which drug?
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What is your current skin care routine?
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Have you had any form of hair removal (wax, laser, electrolysis etc.) done in the past 2 weeks? If yes, please specify.
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What do you love about your skin? (Optional)
What main areas of concern do you have regarding your skin?
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Submit
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