Client Questionnaire

CLIENT QUESTIONNAIRE

First Name *

Last Name *

Phone *

Email *

Address *

Street Address *

City *

State *

Postal code *

Are you interested in payment plans? *

Yes

No

How did you hear about us? *

If referred by a friend, please provide their name

Emergency Contact Name + Phone Number *

HISTORY

Medical + Previous Aesthetic Treatments

If you check any medical issues above, please explain

Please list all allergies, if none type "NA" *

Do you have any medical, health or wellness concerns not already listed? If so, please provide details

If you checked any body sculpting treatments above, please provide date(s), area treated

If you check any of the above facial treatments, please provide date(s) , date of last treatment

Tell me about your daily skin care routine? *

How much caffine do you drink in a day? *

LIFESTYLE

How much alcohol do you drink in a week? *

Do you exercise regularly? (check all that apply) *

In your words, please tell me what's bringing you in today? *

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