Please completely fill out the form below or download the form, print, fill out, and bring with you to your appointment.Client Intake Form Download[ARForms id=105] Client Intake Form Date Today Date Format: MM slash DD slash YYYY Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Mobile Phone*Emergency ContactContact NumberRelationPLEASE CHECK ANY HEALTH CONDITIONS YOU CURRENTLY HAVE OR HAVE HAD IN THE PAST: Cancer Heart Disease HIV or other immune deficiency disorder Liver Disease Diabetes Heart Problems Anxiety Disorder Hormone Imbalance Epilepsy Tuberculosis Hepatitis Herpes or Cold Sore Warts, dermatitis, psoriasis, eczema, impetigo, or MRSA, rosacea, or any other skin disorder Please list all medications, prescription and non-prescription you are currently taking:Do You:Smoke?YesNoUse Tanning Beds?YesNoSunbathe?YesNoPlease list all Allergies:PLEASE CHECK ALL THAT YOU ARE CURRENTLY USING OR HAVE USED IN THE PAST: Oral Contraception Benzoyl Peroxide Daily Aspirin Therapy Salicylic Acid Anti-Coagulant Medication Glycolic Acid Tretinoin, Retin-a, Refissa, Renova, Differen Gel Accutane or Isotretinoin Are you Pregnant or Lactating?YesNoAre you currently taking or have taken Anti-Biotics in the past ten days?YesNoHow did you hear about us?Referred by:What other services do you have interest in? Please check any or all that apply: Permanent Makeup Lash Ext Teeth Whitening Body Sculpting Makeup Application (Take-Home information will be given to you at checkout.)May we use your photos for promo use? Eyes Blocked For No Recognition Full Face Recognition No I Do Not Give Permission To Use My Photos Would you like to receive our newsletter that includes staff specials, promo sales, etc.*YesNoEmail* I CONFIRM THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT MAY BE RELEVANT TO MY TREATMENT.SignatureDate* Date Format: MM slash DD slash YYYY CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.