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Client Information
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Todays Date
*
MM
/
DD
/
YYYY
Date of Birth
*
MM
/
DD
/
YYYY
Referred By-
Your answer
Address
*
Your answer
Phone number
*
Your answer
What are your Skin Concerns?
*
Acne/Breakouts
Fine Lines/Wrinkles
Excessive Oil/Shiny
Rosacea
Broken Capillaries
Redness/Ruddiness
Sun Spots/Liver Spots/Brown Spots
Uneven Skin Tone
Sun Damage
Dull/ Dry Skin
Flaky Skin
Dehydrated
Other:
Required
Have you ever had a facial treatment before? If yes, when?
*
Your answer
Which of the Following best describe your skin type? Choose One.
*
1- Always burns easily, never tans
2- Always burns, tans slightly
3- Burns moderately, tans gradually
4- Seldom burns, always tans well
5- Rarely burns, tans deeply
6- Never burns, deeply tans
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