Please completely fill out the form below or download the form, print, fill out, and bring with you to your appointment.Client Intake Form Download[ARForms id=105] Client Intake Form HiddenDate Today MM slash DD slash YYYY Name* First Last Date of Birth* DD slash MM slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Mobile Phone*Emergency Contact Contact NumberRelation PLEASE CHECK ANY HEALTH CONDITIONS YOU CURRENTLY HAVE OR HAVE HAD IN THE PAST: Cancer Heart Disease HIV or other immune deficiency disorder Liver Disease Diabetes Heart Problems Anxiety Disorder Hormone Imbalance Epilepsy Tuberculosis Hepatitis Herpes or Cold Sore Warts, dermatitis, psoriasis, eczema, impetigo, or MRSA, rosacea, or any other skin disorder Please list all medications, prescription and non-prescription you are currently taking:Do You:Smoke? Yes No Use Tanning Beds? Yes No Sunbathe? Yes No Please list all Allergies:PLEASE CHECK ALL THAT YOU ARE CURRENTLY USING OR HAVE USED IN THE PAST: Oral Contraception Benzoyl Peroxide Daily Aspirin Therapy Salicylic Acid Anti-Coagulant Medication Glycolic Acid Tretinoin, Retin-a, Refissa, Renova, Differen Gel Accutane or Isotretinoin Are you Pregnant or Lactating? Yes No Are you currently taking or have taken Anti-Biotics in the past ten days? Yes No How did you hear about us? Referred by: What other services do you have interest in? Please check any or all that apply: Permanent Makeup Teeth Whitening Makeup Application Laser Treatments Laser Hair Removal Laser Tattoo Removal (Take-Home information will be given to you at checkout.)May we use your photos for promo use? Eyes Blocked For No Recognition Full Face Recognition No I Do Not Give Permission To Use My Photos Would you like to receive our newsletter that includes staff specials, promo sales, etc.* Yes No Email* I CONFIRM THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT MAY BE RELEVANT TO MY TREATMENT.SignatureDate* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
