Dual Aesthetics New Client Info Request
Please fill out the information below to get started with facial treatments with Dual Aesthetics.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Which visit option are you interested in?
*
In-Person
Virtual
Tell me a little bit about your skin journey so far! Include your current skincare routine, previous history with estheticians/dermatologists, and what your skin concerns are…
*
What are your main 3 skin concerns?
*
How long have you been dealing with these skin concerns?
*
Couple weeks
1-3 months
4-6 months
7-12 months
1+ years
Was there a specific facial treatment that intrigued you?
*
Are you currently taking or ever been prescribed any of the following medications?
*
Accutane/Isotretinoin
Tretinoin
Oral Acne Medications
Other
If you checked any of the boxes from the previous question, please write the medication and date you started taking that medication and the date you last took that medication. Put N/A if this does not pertain to you.
*
Are you ready to invest and commit to a fully customized professional grade skincare regimen?
*
Yes
No
Yes, but I have questions/concerns
What are your questions/concerns regarding a skincare regimen based on the response above?
How soon are you wanting to schedule your first appointment?
*
As soon as possible
Within this month
1-2 months out
How did you hear about Dual Aesthetics?
*
Tiktok
Instagram
Facebook
Youtube
Google
Referred by Family/Friend
If referred by Family/Friend, who referred you?
At Dual Aesthetics, we believe transformative skin results are built through consistency, expert care, and a personalized home care routine. By submitting this form, I acknowledge my desire to begin my skincare journey with Dual Aesthetics and understand that appointments are not reserved until I have connected with Hannah or Bella and scheduled my consultation.
*
I understand.
Submit
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