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Skin Serenity Client Intake Form
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Email
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Your email
Name
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Your answer
Date of Birth
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DD
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YYYY
Address
*
Your answer
Phone number
*
Your answer
Drivers License
*
Your answer
Emergency contact
*
Your answer
Emergency contact's phone number
*
Your answer
Procedure
*
Areola Tattoo
Scar Camouflage
Corrective Lip Tattoo
Stretchmarks Camouflage
Radiation Markers
Micro-Needling
Men's Facial Rejuvenation
Other:
Required
Medical history
*
Pregnant/Nursing
TB
HIV
Hepatitis
HSV
Diabetes
Epilepsy
Asthma
Heart Condition
Fainting/Dizziness
Eczema/Psoriasis
Keloids
Latex allergy
I have allergies to metals, soaps, cosmetics, alcohol, or adhesive
I have been prescribed antibiotics prior to dental or surgical procedure
Other:
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Any medical conditions? Please list:
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Your answer
Do you take any medications? Please list:
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Your answer
Today's Date
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YYYY
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