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Date
Name
*
First
Last
Phone
Any changes in medication or supplements?
*
— Select Choice —
Yes
No
What is changes in medication or supplements?
*
Any new skin conditions, allergies, or sensitivities?
*
— Select Choice —
Yes
No
Any new skin conditions, allergies, or sensitivities?
*
Any recent medical changes or procedures?
*
— Select Choice —
Yes
No
What is recent medical changes or procedures?
*
recent new medical
Are you pregnant or any health changes?
*
— Select Choice —
Yes
No
Any metal implants, pacemaker, or medical devices?
*
— Select Choice —
Yes
No
Any new skincare products (retinol, acids, etc.)?
*
— Select Choice —
Yes
No
Have you had any recent waxing, peeling, or exfoliation treatments?
*
— Select Choice —
Yes
No
Signature
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