Client Mini-Intake Form "*" indicates required fields Within the last year, have you been under a physician's care on medication or experienced any health problems including allergies?* Yes No If Yes checked above, please describe here.Do you have any metal implants, pacemaker or body piercings?* Yes No Are you pregnant or trying to become pregnant or lactating?* Yes No Are you currently using any of the products or receiving any of the treatments below? exfoliating products vitamin A derivatives (such as Retinol) Wax (within the last 72 hrs) laser or light theraphy (within the last month) chemical peel (within the last month) microdermabrasion (within the last month) Notes:*Signature (your name submitted below will be considered your electronic signature)* First Last Date Signed* Month Day Year
