Esthetician Intake

    General Information

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    Emergency Contact

    Medical History

    Please check all that apply:

    Are you currently taking any medications?

    Have you had any facial or dermatology services in the past 30 days?

    Do you have any allergies?

    Skin Care History

    Check the products that you currently use (please select all that apply):

    What type of skin do you have?

    Conditions you are currently experiencing today (please select all that apply):

    Important Information

    What concerns do you have regarding your skin? Please select all that apply:

    Have you been under the care of a dermatologist within the past year?

    Have you used Retin-A, Renova, AHAs or Retinal/Vitamin A products in the last three months?

    Have you received Botox, Restylane, or Collagen injections in the last 6 months?

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