Client Mini Intake Form "*" indicates required fields Date* MM slash DD slash YYYY Name* First Last 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, 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) Please share anything you need Angelique to know: (N/A if nothing)*Signature (your name submitted below will be considered your electronic signature)* First Last Date Signed* Month Day Year Δ
