Client Intake Form - Hello Beautiful

First Name *

Last Name *

Date

Date of birth

Age

Gender

Address

Phone

Email Address *

Emergency Contact Name

Emergency Contact Phone

How did you hear about us?

Would you like to be added to our email list for the news and exclusive offers?

Medical History

Do you have or have you had any of the following conditions? If yes, please select them:

Any other condition:

Notes:

Any known allergies?

If so, please list them

List any medications you take regularly, including vitamins, herbal supplements, aspirin

Any recent surgeries, including plastic surgery?

If so, please list them

Are you pregnant or trying to become pregnant?

Have you ever had a treatment before

If so, please explain

What would you like to achieve from your treatment today?

Skin Care

Please select any current products you are using:

Skin History

What is your skin type?

Your exposure to the sun?

What type of foundation do you wear?

How does your skin heal?

Do you get bruises easily?

Skin Concerns

If you selected other please explain

Medications

Have you ever used acne medication?

If yes when?

Which drug?

Have you in the last 3 months used Retin-A, Renova, AHA's or Retinol/Vitamin A derivative products?

If yes, please describe

Have you recieved Botox, Restylane, or Collagen injections in the last 6 months?

If yes, please describe

Please type your name *

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