Client Intake Form

NICE TO MEET YOU

First Name *

Last Name *

Date of Birth *

Address *

City *

State *

Postal code *

Cell Phone *

Home Phone

Work Phone

Email *

Monthly Specials & Events Notification Consent. Circle all that apply. *

Telephone

Text Message

Appointment Notification Consent. Circle all that apply. *

Telephone

Text Message

What is the nature of your visit? *

Occupation *

How did you hear about us? If Referred by a client, please list their name. *

Emergency contact name and phone number *

Click on the '>' in the bottom right-hand corner to continue

TERMS

24 HOUR CANCELLATION POLICY

Appointments that are cancelled with less than 24 hour notice will be charged 50% of the service. "No-Show" appointments will be charged 100% of the service. Medical appointments with Same Day Cancellations/No-Show will be charged $100. The credit card that is used to hold the appointment will be charged in accordance to the above Cancellation Policy.

PAYMENT POLICY

Payment is due in full upon completion of service.

Do you understand that every procedure/operation is followed by a period of healing before the tissue returns to normal and the final result is apparent? *

Yes

Do you understand that the objective of any cosmetic procedure is an improvement, not perfection? *

Yes

Patient Signature (Terms) *

Clear

Parent/Guardian Signature (If under the age of 18 years)

Clear

Click on the '>' in the bottom right-hand corner to continue

Date (Terms)

SKIN TYPING MATRIX

Please answer the following questions by choosing which option best describes you. Your clinician will total your score during the consultation.

My ethnic origin is closest to: *

My eye color is: *

My natural hair color at age 18 was: *

The color of my skin that is not normally exposed to sun is: *

If I go out into the sun for an hour or so without sunscreen and have not been out in the sun for weeks, my skin will: *

If you sustain an injury to your skin such as a cut, burn, or bruise, how long does it take to fully resolve without any hyperpigmentation? *

If you get an insect bite, are you left with a brown spot? *

Do you ever get "cold sores" or "fever blisters"?