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NEW CLIENT FORM

Flamingo Shape

Please fill out the following form prior to your appointment.

Gender
Does your job require you to work outdoors?

YOUR SKIN CARE

Have you ever had a facial treatment before?
Have you ever had a body spa treatment before?
Which of the following best describes your skin type?
Have you ever had chemical peels, laser treatments, or microdermabrasion?
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?
Have you used acne medication?
Have you experienced Botox, Restylane, or collagen injections?
Have you had any in the past month?

LIFESTYLE

Which of the following best describes your skin type?
How many alcoholic beverages do you consume per week?
Which foods do you consume on a regular basis? Required
How often do you travel on a plane?
Do you exercise on a regular basis?
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?
How many hours of sleep do you get per night?
What does your daily commute look like?
How many hours do you spend in front of a screen or digital device?
Do you smoke cigarettes, vape, or consume other tobacco products?
What are your stress levels on a scale from 1 to 5(1 = low stress, 5 = high stress)?
Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatments?
Are you pregnant or trying to become pregnant?
Are you experiencing any menopausal symptoms?
Are you undergoing any hormone replacement therapy treatments?
Do you experience ingrown hairs as a result of hair removal?

Future Appointments/Contact

May I call you at the provided phone number to confirm future appointments?
May I contact you via mail/email about future promotions and news?

By hitting submit, I understand, and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Thanks for submitting!

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