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Client Intake Form

Client Information

Birthday
Month
Day
Year

Medical History

Please check all that apply:
Are you currently taking any medications?
Yes
No
Are you currently taking any supplements?
Yes
No
Do you have any allergies?
Yes
No

Skin Care History

Have you been under the care of a dermatologist within the past year?
Yes
No
Have you had any facial or dermatology services in the past 30 days?
Yes
No
What skin type do you feel you have?
Normal
Oily
Sensitive
Combination
Dry
Unsure
What concerns do you have regarding your skin? (Please select all that apply)
Have you used Retin-A, Retinol/Vitamin A, Tretinoin or Vitamin C products within the last 3 months?
Have you received Botox, Juvederm, Restylane, Kybella or any other injections in the last 6 months?
Check the products that you currently use (please select all that apply):

By signing below, I agree to the following:


I have completed this form to the best of my ability and knowledge. I agree to inform my Aesthetician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested/recommended treatment unsuitable. I will inform my Aesthetician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my Aesthetician and Poise Aesthetics for any injury or damages incurred due to any misrepresentation of my health. 

Date
Month
Day
Year
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