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Lumera Skin Studio — Client Intake & Consultation Form
Thank you for your interest in Lumera Skin Studio. Please complete this form so we can learn more about your treatment goals and determine whether you may be a suitable candidate for treatment. All new clients are reviewed prior to booking. Submitting this form does not guarantee an appointment. If you are approved to proceed, you will receive instructions for scheduling your appointment.Please answer all questions honestly and completely.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Preferred Contact Method
*
Phone
Text
Email
How did you hear about Lumera Skin Studio?
What Paramedical Tattoo service (s) are you interested in? (Select all that apply)
*
Scar or Stretchmark Ink Camouflage Tattoo
Scar / Stretchmark Treatment
Acne Scar Revision
ABOUT THE AREA YOU WANT TREATED
Where is the area located?
*
What caused the scar?
*
Is there currently any open skin, scabbing, bleeding drainage, drainage, significant redness, swelling, active rash, or infection?
*
Have you had any previous treatments performed on this area such as laser, microneedling etc.? If so, what treatments have been done and when?
*
Do you have any known allergies?
*
Yes
No
Please list allergies if this applies
Are you currently taking any medications that may affect bleeding, healing, or your skin?
*
Yes
No
Do you have any medical conditions that may affect healing?
*
Yes
No
Have you ever been diagnosed with or treated for any of the following conditions?
*
Autoimmune Disorder
Bleeding Disorders
Cold Sores/Herpes Simplex
Type option 4
Cancer
Chemical Peel
Diabetes
Dermatitis / Eczema
Hepatitis
HIV / AIDS
Tumors/Growths/Cysts
Keloid Scarring
Difficulty Numbing
Heart Conditions
Liver Conditions
Skin Diseases
Skin Sensitivity
OTHER
NONE OF THE ABOVE
Do you have diabetes or blood sugar related conditions?
*
Yes
No
Have you ever experienced an allergic reaction to tattoo ink, pigments, numbing products or topical products?
*
Yes
No
How would you describe the area you would like treated?
*
Flat
Raised
Indented
Discolored
Darker than surrounding skin
Lighter than surrounding skin
PHOTO UPLOAD
Please upload clear photos of the area you would like evaluated. Please take your photos in good, natural lighting. Keep camera approx 2-3 feet away and make sure entire treatment is visible. Please do not use filters or editing apps. Upload 2-4 clear photos from different angles.
📷 Treatment Area Photos
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
AVAILABILITY - What days generally work best for you?
Type a question
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Time:
*
Morning
Afternoon
Evening
I understand that submitting this form is a request for a consultation and/or appointment consideration. I understand that completion of this form does not guarantee that i am a candidate for treatment or that an appointment will be scheduled. I certify that the information I have provided is accurate and complete to the best of my knowledge. I understand that additional information may be requested before treatment is approved.
*
I AGREE and UNDERSTAND
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