New Client Intake Form

Hi there! To make sure your experience is as tailored and effective as possible, I kindly ask you to take a moment to fill out the following information thoroughly. Think of your skincare journey with me starting days before we even meet. I'll be delving into everything you've used in the past, including any medications or health conditions you've experienced. This preparation is crucial for me to provide you with the best possible care at your upcoming appointment. Once this is completed you will be sent to the online scheduling page.

First and Last Name

Phone

What is your current age?

What is your Sex?

Male

Female

Does anyone in your family have acne?

Please mark any of the following medications you have used in the last 5 years.

Please list any other medications you have used or are currently taking.

Are you allergic to:

Latex

Sulfer

Asprin

N/A

List any other allergies you know of

Do you currently use birth control pills, shots, or an IUD?

Yes

If YES, please list the name

Please list all the skincare products you are currently using. (please be specific with brand and name of the product)

Please upload current photos of your skin. Skin must be freshly washed and camera cropped in.

Front Face

Right Side

Left Side

Tell me all the things about you, your acne struggles, how you found me:)

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New Client Intake Form

New Client Intake Form

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