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Facial Intake form

Birthday

Intake

Skin Health

What best describes your skin when exposed to direct sunlight?
What is your skin type?
How does your skin heal?
Does your skin bruise easily?

Skin Concerns

What are your skin concerns?

Skin Care

Do you have a daily skincare routine?
Have you had a professional facial before?
Have you had any of the following?
Have you experienced any of the following?

Lifestyle

Are you physically active?
Do you travel a lot?
Do you work?
Yes
No
Other
What does your diet look like?
Are you willing to make changes in your lifestyle to keep your skin health at its best? (Keeping up with treatments, cutting out harmful foods, scheduling around physical activity, etc)
Yes
No
Other
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