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Advanced Skin Treatments Intake Form

HEALTH & MEDICAL HISTORY

Are you pregnant or breastfeeding?
YES
NO
Do you have any allergies? (skincare, fragrance, latex, etc.)
YES
NO
Are you currently taking any medications?
YES
NO
Do you have any medical conditions?

SKIN HISTORY

How would you describe your skin type?
Oily
Dry
Combination
Normal
Sensitive
What are your main skin concerns? (check all that apply)

CURRENT SKINCARE ROUTINE

What skincare products do you currently use?

FACIAL HISTORY

Have you had a facial before?
YES
NO
Have you had any of the following recently?

SENSITIVITY CHECK

Does your skin react easily?
YES
NO
Do you experience any of the following?

CONSENT

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