Wildflower Esthetics - Client Intake Form
Please complete this form prior to your appointment.
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Emergency Contact Name:
*
First Name
Last Name
Emergency Contact Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please check any that apply:
*
Pregnant or breastfeeding
Diabetes
Skin condition (psoriasis, eczema, etc.)
Cold sores/herpes simplex
Accutane in the last 12 months
Retin-A/Tretinoin/AHAs/BHAs
Allergies (latex, nuts, lidocaine, etc.)
Recent Botox, fillers, laser, or peel treatments
None of the above
Please list any allergies or medications we should know about:
*
If none, please fill in "N/A"
Submit
Should be Empty: